Evaluation of the diagnostic accuracy of CEUS in children with benign and malignant liver lesions and portal vein anomalies

Clinical applications of superb microvascular imaging and virtual touch imaging quantification in pediatric mesenteric lymphadenitis diagnosis: A promising pathway to enhanced precision

BACKGROUND

Mesenteric lymphadenitis (ML) demonstrates a distinctive inclination for the pediatric and adolescent demographic and the diagnosis of ML in young children poses a substantial challenge.

OBJECTIVE

This prospective study aimed to assess the diagnostic efficacy of Superb Microvascular Imaging (SMI) and Virtual Touch Tissue Imaging quantification (VTIQ) in distinguishing pediatric mesenteric lymphadentitis.

METHODS

We examined 82 mesentric lymph node (MLN) in pediatric patients with mesenteric lymphadentitis and 50 MLN in a healthy group. SMI was utilized to evaluate vascularity within the MLN, while MLN stiffness, quantified as shear wave velocity (SWV) in meters per second (m/s), was assessed using VTIQ. We compared the diagnostic performance of greyscale Ultrasound, US combined with SMI, US combined with VTIQ, and US combined with both SMI and VTIQ.

RESULTS

SMI revealed a significant distinction between mesenteric lymphadentitis and normal MLN (p <  0.001). MLN affected by mesenteric lymphadentis exhibited increased vascularity (marked vascularity: 13/82, 15.85%) compared to normal MLN (marked vascularity: 1/50, 2.00%). Statistically significant differences were observed in SWV values beween mesenteric lymphadentitis and normal MLN (all p-values <0.001). The mean and minimum SWV values for MLN with mesenteric lymphadentitis were 1.66±0.77 m/s and 1.51±0.53 m/s, respectively. Control group SWV values were approximately three times higher than those in the mesenteric lymphadenitis group. The highest area under the curve values were achieved with the combination of all three modalities (0.837, 95% confidence interval: 0.763- 0.896), followed by US + VTIQ (0.795, 0.716- 0.860), US + SMI (0.753, 0.670- 0.824) and US alone (0.642, 0.554- 0.724).

CONCLUSION

SMI and VTIQ offer a promising noninvasive adjunct to grayscale ultrasound for identifying mesenteric lymphadentitis in pediatric patients.

Application of Quantitative Parameters of Contrast-Enhanced Ultrasound in Common Benign and Malignant Lesions in Pediatric Livers: A Preliminary Study

We aimed to investigate the diagnostic utility of quantitative parameters of contrast-enhanced ultrasound (CEUS) for benign and malignant liver lesions in pediatric patients. This was a single-center retrospective analysis of children with liver lesions who underwent CEUS at our hospital between July 2019 and February 2023. The CEUS perfusion patterns for all lesions were qualitatively analyzed using histopathology, contrast-enhanced magnetic resonance imaging, contrast-enhanced computed tomography, or long-term clinical follow-up as reference standards. The CEUS images were quantitatively analyzed using SonoLiver® software (TomTec Imaging Systems, Munich, Germany) to obtain data regarding quantitative parameters and dynamic vascular pattern (DVP) parametric images, including rise time (RT), time to peak (TTP), mean transit time (mTT), and maximum intensity (IMAX). Statistical analysis was carried out using Student's t-test and receiver operating characteristic (ROC) curve analysis to evaluate the diagnostic value of quantitative parameters. A total of 53 pediatric cases were included in this study, and 88.57% (31/35) of malignant lesions exhibited hyper-enhancement with rapid washout patterns; the same proportion of DVP parametric images exhibited washout patterns. Conversely, 94.44% (17/18) of benign lesions showed hyper-enhancement with slow washout patterns, and the same proportion of DVP parametric images showed no-washout patterns. RT, TTP, and mTT were significantly shorter in the malignant group than in the benign group (p < 0.05), while IMAX showed no significant difference (p > 0.05). ROC analysis indicated that mTT < 113.34 had the highest diagnostic value, with an area under the curve of 0.82. CEUS quantitative analysis had an accuracy of 98.11%, while qualitative analysis had an accuracy of 92.45%, with no statistically significant difference (p > 0.05). Quantitative analysis of CEUS provides valuable assistance in differentiating benign and malignant liver lesions in children. Among all quantitative parameters, mTT holds promise as a potentially valuable tool for identifying liver tumors.

Utility of the pediatric liver contrast-enhanced ultrasound criteria in differentiating malignant and benign multifocal lesions

BACKGROUND

The pediatric liver contrast-enhanced ultrasound (CEUS) criteria were developed to improve the diagnostic performance of CEUS in differentiating pediatric benign and malignant liver lesions. However, the diagnostic performance of CEUS in the evaluation of multiple focal liver lesions in the pediatric population has not yet been fully evaluated.

OBJECTIVE

To evaluate the diagnostic performance of the pediatric liver CEUS criteria in differentiating benign and malignant multifocal liver lesions in children.

MATERIALS AND METHODS

From April 2017 to September 2022, the CEUS characteristics of multifocal liver lesions in patients < 18 years were analyzed. Lesions classified as CEUS-1, CEUS-2 or CEUS-3 were considered benign and lesions classified as CEUS-4 or CEUS-5 were considered malignant. The diagnostic performance of the pediatric liver CEUS criteria (i.e. sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV] and accuracy) was assessed.

RESULTS

After exclusion, 21 patients (median age, 36.0 months; range, 1.0-204 months; 7 boys) were included. There were significant differences in the serum alpha fetoprotein level (P= 0.039) and the presence of washout (P < 0.001) between children with malignant and benign lesions. The sensitivity, specificity, PPV, NPV and accuracy of the pediatric liver CEUS criteria were 100.0% (10/10), 90.9% (10/11), 90.9% (10/11), 100.0% (10/10) and 95.2% (20/21), respectively.

CONCLUSION

The pediatric liver CEUS criteria had excellent diagnostic performance in differentiating benign and malignant multifocal liver lesions in children.

Current aspects of multimodal ultrasound liver diagnostics using contrast-enhanced ultrasonography (CEUS), fat evaluation, fibrosis assessment, and perfusion analysis - An update

Current ultrasound multifrequency probes allow both improved detail resolution and depth of penetration when examining the liver. Also, new developments in vascular diagnostics, elastography with fibrosis assessment, evaluation of possible steatosis, and parametric and time intensity curve (TIC) analysis of dynamic microvascularization of the liver with contrast-enhanced ultrasound sonography (CEUS) complement ultrasound-guided diagnostics. State-of-the-art high-resolution technology includes a high frame rate (HiFR) mode for CEUS, fast shear wave measurements with the sound touch quantify (STQ) mode, artifact-free flow detection using HR flow and glazing flow in combination with a special flow-adapted imaging (Ultra Micro Angiography, UMA) and additionally different assessments of possible fatty liver (UltraSound ATtenuation Imaging Technology, USAT). In 50 cases with focal liver lesions, a multimodal liver diagnosis was performed with a still new high-performance ultrasound system as part of the clarification of questions from the university liver consultation and tumor outpatient clinic.

Modified contrast-enhanced ultrasonography with the new high-resolution examination technique of high frame rate contrast-enhanced ultrasound (HiFR-CEUS) for characterization of liver lesions: First results

AIM

To examine to what extent the high frame rate contrast-enhanced ultrasound (HiFR) diagnostic enables the conclusive diagnosis of liver changes with suspected malignancy.

MATERIAL/METHODS

Ultrasound examinations were performed by an experienced examiner using a multifrequency probe (SC6-1) on a high-end ultrasound system (Resona 7, Mindray) to clarify liver changes that were unclear on the B-scan. A bolus of 1-2.4 ml of the Sulphur hexafluoride ultrasound microbubbles contrast agent SonoVue™ (Bracco SpA, Italy) was administered with DICOM storage of CEUS examinations from the early arterial phase (5-15 s) to the late phase (5-6 min). Based on the image files stored in the PACS, an independent reading was performed regarding image quality and finding-related diagnostic significance (0 not informative/non-diagnostic to 5 excellent image quality/confident diagnosis possible). References were clinical follow-up, if possible, comparison to promptly performed computed tomography or magnetic resonance imaging, in some cases also to histopathology.

RESULTS

We examined 100 patients (42 women, 58 men, from 18 years to 90 years, mean 63±13 years) with different entities of focal and diffuse liver parenchymal changes, which could be detected in all cases with sufficient image quality with CEUS and with high image quality with HiFR-CEUS. Proportionally septate cysts were found in n = 19 cases, scars after hemihepatectomy with local reduced fat in n = 5 cases, scars after microwave ablation in n = 19 cases, hemangiomas in n = 9 cases, focal nodular hyperplasia in n = 8 cases, colorectal metastases in n = 15 cases, hepatocellular carcinoma (HCC) in n = 11 cases, Osler disease in n = 8 cases. The size of lesions ranged from 5 mm to 200 mm with a mean value of 33.1±27.8 mm. Conclusive diagnoses could be made by the experienced investigator in 97/100 cases with CEUS, confirmed by reference imaging, in parts by histopathology or follow-up. The image quality for HiFR CEUS was rated with a score of 3 to 5; 62 cases were assessed with an average of good (4 points), 27 cases with very good (5 points), and in 11 cases (3 points) still satisfactory despite aggravated acoustic conditions. The specificity of HIFR-CEUS was 97%, the sensitivity 97%, the positive predictive value 94%, the negative predictive value 99% and the accuracy 97%.

CONCLUSION

HIFR-CEUS has demonstrated has demonstrated an improved image quality resulting in a high diagnostic accuracy. In the hands of an experienced investigator, HiFR-CEUS allows the assessment of focal and diffuse unclear liver parenchymal changes on B-scan and dynamic assessment of microcirculation in solid and vascular changes.

Contrast-enhanced ultrasound: a comprehensive review of safety in children

Contrast-enhanced ultrasound (CEUS) has been increasingly used in pediatric radiology practice worldwide. For nearly two decades, CEUS applications have been performed with the off-label use of gas-containing second-generation ultrasound contrast agents (UCAs). Since 2016, the United States Food and Drug Administration (FDA) has approved the UCA Lumason for three pediatric indications: the evaluation of focal liver lesions and echocardiography via intravenous administration and the assessment of vesicoureteral reflux via intravesical application (contrast-enhanced voiding urosonography, ceVUS). Prior to the FDA approval of Lumason, numerous studies with the use of second-generation UCAs had been conducted in adults and children. Comprehensive protocols for clinical safety evaluations have demonstrated the highly favorable safety profile of UCA for intravenous, intravesical and other intracavitary uses. The safety data on CEUS continue to accumulate as this imaging modality is increasingly utilized in clinical settings worldwide. As of August 2021, 57 pediatric-only original research studies encompassing a total of 4,518 children with 4,906 intravenous CEUS examinations had been published. As in adults, there were a few adverse events; the majority of these were non-serious, although very rarely serious anaphylactic reactions were reported. In the published pediatric-only intravenous CEUS studies included in our analysis, the overall incidence rate of serious adverse events was 0.22% (10/4,518) of children and 0.20% (10/4,906) of all CEUS examinations. Non-serious adverse events from the intravenous CEUS were observed in 1.20% (54/4,518) of children and 1.10% (54/4,906) of CEUS examinations. During the same time period, 31 studies with the intravesical use of UCA were conducted in 12,362 children. A few non-serious adverse events were encountered (0.31%; 38/12,362), but these were most likely attributable to the bladder catheterization rather than the UCA. Other developing clinical applications of UCA in children, including intracavitary and intralymphatic, are ongoing. To date, no serious adverse events have been reported with these applications. This article reviews the existing pediatric CEUS literature and provides an overview of safety-related information reported from UCA uses in children.

Development of a pediatric liver CEUS criterion to classify benign and malignant liver lesions in pediatric patients: a pilot study

OBJECTIVES

To analyze the contrast-enhanced ultrasound (CEUS) characteristics of pediatric patients with focal liver lesions (FLLs) and develop a pediatric liver CEUS criterion to improve the diagnostic performance of CEUS in differentiating pediatric benign and malignant liver lesions.

METHODS

Between March 2011 and May 2020, patients < 18 years who underwent CEUS were retrospectively evaluated. The CEUS characteristics of FLLs were analyzed. A pediatric liver CEUS criterion categorized as CEUS-1 to CEUS-5 was developed. The diagnostic performance of the criterion (i.e., sensitivity, specificity, PPV, and NPV) was assessed. Chi-square and Mann-Whitney tests were used.

RESULTS

After exclusion, the study included 130 lesions (mean diameter, 7.1 cm; range, 0.8-17.0 cm) from 130 patients (mean age, 36.0 months; range, 0.03-204.0 months; 74 boys). Hyperenhancement with washout in patients < 5 years or with early washout (≤ 45 s) was used to predict hepatoblastoma, with a sensitivity and specificity of 90.7% (95% confidence interval [CI]: 77.9%, 97.4%) and 93.6% (95% CI: 84.3%, 98.2%), respectively. Peripheral discontinuous globular hyperenhancement was used to diagnose hemangioma, with a sensitivity and specificity of 84.6% (95% CI: 65.1%, 95.6%) and 100% (95% CI: 95.4%, 100.0%), respectively. The rates of malignancies within the pediatric liver CEUS-1, CEUS-2, CEUS-3, CEUS-4, and CEUS-5 categories were 0.0%, 0.0%, 5.6%, 50.0%, and 96.1%, respectively. Besides, the incidences of hepatoblastoma in pediatric liver CEUS-3, CEUS-4, and CEUS-5 were 5.6%, 16.7%, and 67.5%, respectively.

CONCLUSIONS

The pediatric liver CEUS criterion is useful in differentiating benign focal liver lesions from malignancies, especially hepatoblastoma from hemangioma.

KEY POINTS

• Hyperenhancement with washout in patients <v5 years or with early washout (≤ 45 s) were used to predict hepatoblastoma, with a sensitivity and specificity of 90.7% and 93.6%. • Peripheral discontinuous globular hyperenhancement was used to diagnose hemangioma, with a sensitivity and specificity of 84.6% and 100.0%. • The rates of malignancies within the pediatric liver CEUS-1, CEUS -2, CEUS-3, CEUS-4, and CEUS-5 categories were 0.0%, 0.0%, 5.6%, 50.0%, and 96.1%, respectively.

Contrast-enhanced ultrasound of benign and malignant liver lesions in children

Contrast-enhanced ultrasound (CEUS) is increasingly being used in children. One of the most common referrals for CEUS performance is characterization of indeterminate focal liver lesions and follow-up of known liver lesions. In this setting, CEUS is performed with intravenous administration of ultrasound contrast agents (UCAs). When injected into a vein, UCA microbubbles remain confined within the vascular network until they dissipate. Therefore, visualization of UCA within the tissues and lesions corresponds to true blood flow. CEUS enables continuous, real-time observation of the enhancement pattern of a focal liver lesion, allowing in most cases for a definite diagnosis and obviating the need for further cross-sectional imaging or other interventional procedures. The recent approval of Lumason (Bracco Diagnostics, Monroe Township, NJ) for pediatric liver CEUS applications has spurred the widespread use of CEUS. In this review article we describe the role of CEUS in pediatric liver applications, focusing on the examination technique and interpretation of main imaging findings of the most commonly encountered benign and malignant focal liver lesions. We also compare the diagnostic performance of CEUS with other imaging modalities for accurate characterization of focal liver lesions.

The Safety and Effectiveness of Intravenous Contrast-Enhanced Sonography in Chinese Children-A Single Center and Prospective Study in China

Background and Objective: Intravenous contrast-enhanced ultrasound (CEUS), using the second-generation ultrasound contrast agent SonoVue^®, has been widely used in adults. In 2016, it was approved for pediatric applications by the American Food and Drug Administration (FDA). However, it has not been approved by the Chinese Food and Drug Administration (CFDA). The objective of the study was to evaluate the safety and effectiveness of CEUS in children prospectively at a single center in China. Methods: A total of 312 cases of Chinese children were enrolled in clinical trials. Contrast agent was given intravenously with two different doses, including 2.4 ml/time and 0.03 ml/kg. All CEUS was performed for evaluating adverse effect and the diagnostic accuracy compared with the pathology and enhanced CT. Results: All 312 subjects underwent CEUS successfully. The dose of contrast agent for CEUS was 2.4 ml between November 2015 and June 2016, which was modified to 0.03 ml/kg between July 2016 and April 2019, according to the recommendation of the FDA. With the two different doses of the contrast agent, the heart rate, respiration rate, oxygen saturation, and blood pressure of the participants had no statistically significant difference (P > 0.05) before and after administration. The blood pressure had been significantly decreased in participants who received combined anesthetic administration. Following 600 intravenous injections of the CEUS, there were three cases of transient rash and three cases of hypotension (n = 6, 1.92%). The six recovered quickly after receiving intravenous methylprednisolone and epinephrine. Most of the studies were performed for evaluating renal microcirculation and assisting renal biopsy (192/312 [61.5%]), which together had a 98.9% effectiveness in the identification of pathology in the specimens. Some studies were conducted to identify a mass in the liver, retroperitoneum, abdominal cavity, kidneys, testicles, thyroid, and so on (99/312 [31.4%]), which had a 97.6% accuracy. The other studies were conducted to identify trauma, vascular malformation, infection, hemorrhage, and so on (21/312 [6.73%]), which had a similar accuracy to enhanced CT. Conclusion: The adverse effects of CEUS in children are similar to that in adults. The results indicate that it is safe to use SonoVue^® for CEUS in pediatric patients.

[Contrast-enhanced ultrasound (CEUS) and image fusion for procedures of liver interventions]

CLINICAL/METHODICAL ISSUE

Contrast-enhanced ultrasound (CEUS) is becoming increasingly important for the detection and characterization of malignant liver lesions and allows percutaneous treatment when surgery is not possible. Contrast-enhanced ultrasound image fusion with computed tomography (CT) and magnetic resonance imaging (MRI) opens up further options for the targeted investigation of a modified tumor treatment.

METHODICAL INNOVATIONS

Ultrasound image fusion offers the potential for real-time imaging and can be combined with other cross-sectional imaging techniques as well as CEUS.

PERFORMANCE

With the implementation of ultrasound contrast agents and image fusion, ultrasound has been improved in the detection and characterization of liver lesions in comparison to other cross-sectional imaging techniques. In addition, this method can also be used for intervention procedures. The success rate of fusion-guided biopsies or CEUS-guided tumor ablation lies between 80 and 100% in the literature.

ACHIEVEMENTS

Ultrasound-guided image fusion using CT or MRI data, in combination with CEUS, can facilitate diagnosis and therapy follow-up after liver interventions.

PRACTICAL RECOMMENDATIONS

In addition to the primary applications of image fusion in the diagnosis and treatment of liver lesions, further useful indications can be integrated into daily work. These include, for example, intraoperative and vascular applications as well applications in other organ systems.

Contrast-enhanced ultrasound in the diagnosis of pediatric focal nodular hyperplasia and hepatic adenoma: interobserver reliability

BACKGROUND

Focal nodular hyperplasia and hepatic adenoma are rare liver tumors in which specific features on contrast-enhanced ultrasound (US) have been reported but are little known in children.

OBJECTIVE

To assess the interobserver agreement in diagnosing and differentiating focal nodular hyperplasia and hepatic adenoma in children using established adult contrast-enhanced US characteristics.

MATERIALS AND METHODS

Thirty children with a definite or probable diagnosis of focal nodular hyperplasia or hepatic adenoma on magnetic resonance imaging (MRI)/histology who underwent contrast-enhanced US studies were included. Typical and additional contrast-enhanced US features of focal nodular hyperplasia and hepatic adenoma were included. The lesions were classified as definite/probable focal nodular hyperplasia, definite/probably hepatic adenoma or unclassified. The interobserver kappa of contrast-enhanced US characteristics was calculated.

RESULTS

Focal nodular hyperplasia and hepatic adenoma in children demonstrate contrast-enhanced US characteristics similar to those in adults. Among the nine lesions with confirmed histological diagnosis, correct diagnosis was made in 7 (77.8%) based on contrast-enhanced US criteria. Two lesions were unclassified by both observers due to a mixed arterial filling pattern. Interobserver kappa for contrast-enhanced US diagnosis was 0.64 (P<0.0001).

CONCLUSION

There is a good interobserver kappa for separating focal nodular hyperplasia from hepatic adenoma in children using established adult contrast-enhanced US features.

Combination of acoustic radiation force impulse imaging, serological indexes and contrast-enhanced ultrasound for diagnosis of liver lesions

AIM

To assess the value of combined acoustic radiation force impulse (ARFI) imaging, serological indexes and contrast-enhanced ultrasound (CEUS) in distinguishing between benign and malignant liver lesions.

METHODS

Patients with liver lesions treated at our hospital were included in this study. The lesions were divided into either a malignant tumor group or a benign tumor group according to pathological or radiological findings. ARFI quantitative detection, serological testing and CEUS quantitative detection were performed and compared. A comparative analysis of the measured indexes was performed between these groups. Receiver operating characteristic (ROC) curves were constructed to compare the diagnostic accuracy of ARFI imaging, serological indexes and CEUS, alone or in different combinations, in identifying benign and malignant liver lesions.

RESULTS

A total of 112 liver lesions in 43 patients were included, of which 78 were malignant and 34 were benign. Shear wave velocity (SWV) value, serum alpha-fetoprotein (AFP) content and enhancement rate were significantly higher in the malignant tumor group than in the benign tumor group (2.39 ± 1.20 m/s vs 1.50 ± 0.49 m/s, 18.02 ± 5.01 ng/mL vs 15.96 ± 4.33 ng/mL, 2.14 ± 0.21 dB/s vs 2.01 ± 0.31 dB/s; P < 0.05). The ROC curve analysis revealed that the areas under the curves (AUCs) of SWV value alone, AFP content alone, enhancement rate alone, SWV value + AFP content, SWV value + enhancement rate, AFP content + enhancement rate and SWV value + AFP content + enhancement rate were 85.1%, 72.1%, 74.5%, 88.3%, 90.4%, 82.0% and 92.3%, respectively. The AUC of SWV value + AFP content + enhancement rate was higher than those of SWV value + AFP content and SWV value + enhancement rate, and significantly higher than those of any single parameter or the combination of any two of parameters.

CONCLUSION

The combination of SWV, AFP and enhancement rate had better diagnostic performance in distinguishing between benign and malignant liver lesions than the use of any single parameter or the combination of any two of parameters. It is expected that this would provide a tool for the differential diagnosis of benign and malignant liver lesions.

Malignancies after liver transplantation: Value of contrast-enhanced ultrasound (CEUS)

PURPOSE

To evaluate the sensitivity and specificity of contrast-enhanced ultrasound (CEUS) and computed tomography (CT) in the diagnosis of malignancies after liver transplantation.

MATERIALS AND METHODS

A total of 23 patients with suspicious liver masses after liver transplantation with initial imaging series between September 2006 and September 2015 were statistically analysed. CEUS and CT were compared in their diagnosis of malignancy with CT being the gold standard. Out of 23 patients 9 patients showed malignant masses in CT, which could also be detected in 7 out 9 of cases using CEUS.

RESULTS

CEUS showed a sensitivity of 77.8%, a specificity of 100.0%, a positive predictive value (PPV) of 100.0% and a negative predictive value (NPV) of 87,5% in comparison with CT being the gold standard. In 2 cases CT showed a malignancy, contrary to the CEUS examination that was reported as normal.

CONCLUSION

CEUS seems to be an alternative option for the evaluation of malignant masses in liver transplant patients. CEUS shows a high specificity and PPV in the detection of malignant liver masses.

Enhancing the role of paediatric ultrasound with microbubbles: a review of intravenous applications

Contrast-enhanced ultrasound (CEUS) represents a complementary technique to greyscale and colour Doppler ultrasonography which allows for real-time visualization and characterization of tissue perfusion. Its inherent advantages in the child makes ultrasonography an ideal imaging modality; repeatability and good tolerance along with the avoidance of CT, a source of ionizing radiation, renders ultrasonography imaging desirable. Although currently paediatric CEUS is principally used in an "off-label" manner, ultrasonography contrast agents have received regulatory approval for assessment of paediatric focal liver lesions (FLL) in the USA. The safety of ultrasound contrast-agents is well documented in adults, as safe as or even surpassing the safety profile of CT and MR contrast agents. Except for the established intracavitary use of CEUS in voiding urosonography, i.v. paediatric applications have been introduced with promising results in the abdominal trauma initial diagnosis and follow-up, characterization and differential diagnosis of FLL and characterization of lung, pleura, renal and splenic pathology. CEUS has also been used to detect complications after paediatric transplantation, evaluate inflammatory bowel disease activity and assess tumour response to antiangiogenic therapy. The purpose of this review was to present these novel i.v. paediatric applications of CEUS and discuss their value.