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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.

Liver cirrhosis is an established high-risk factor for HCC and the majority of patients diagnosed with HCC have cirrhosis. However, HCC also arises in non-cirrhotic livers in approximately 20 %of all cases. HCC in non-cirrhotic patients is often clinically silent and surveillance is usually not recommended. HCC is often diagnosed at an advanced stage in these patients. Current information about HCC in patients with non-cirrhotic liver is limited. Here we review the current knowledge on epidemiology, clinical features and imaging features of those patiens.

In this series of papers on comments and illustrations of the World Federation for Medicine and Biology (WFUMB) guidelines on contrast enhanced ultrasound (CEUS) the topics of bacterial infections are discussed. Improved detection and characterization of common focal liver lesions (FLL) are the main topics of these guidelines but detailed and illustrating information is missing. The focus in this paper on infectious (bacterial) focal liver lesions is on their appearance on B-mode and Doppler ultrasound and CEUS features. Knowledge of these data should help to raise awareness of these rarer findings, to think of these clinical pictures in the corresponding clinical situation, to interpret the ultrasound images correctly and thus to initiate the appropriate diagnostic and therapeutic steps in time.

This multicenter retrospective study highlights the contrast-enhanced ultrasound (CEUS) findings in a series of histologically proven solitary necrotic nodules (SNN) of the liver, a poorly understood pathologic entity of uncertain origin that mimics malignancy. 22 patients (M/F 13/9; mean age 59.4 years, SD ± 10.7, range 35-81) with histological diagnosis of SNN and CEUS were selected from clinical, imaging, and pathological archives of 7 US interventional centers, each of which provided 1 to 6 cases (mean 2.8). Pathological diagnosis was made on 20 US-guided biopsies and 2 surgical specimens. 2 patients had 2 SNNs with identical CEUS findings so that imaging analysis was carried out on 24 nodules. SNN was an incidental finding in healthy people in 10 cases (45.5 %), and it was discovered during follow-up for either known extrahepatic malignancies (9 cases = 41 %) or chronic liver disease (3 cases = 13.5 %). SNNs had a mean size of 19.3 mm (SD ± 6.5, range 9-40). On B-mode US, SNNs appeared hypoechoic in 14 cases (66.7 %), "target-like" in 7 cases (29.2 %), and homogeneously hyperechoic in 1 case (4.1 %). On CEUS, all lesions appeared devoid of contrast enhancement ("punched out" aspect) in the arterial, portal venous, and late phases after US contrast agent injection. A uniformly thin, hyperenhancing ring in the early arterial phase and isoenhanced with the surrounding parenchyma in the portal venous and late phases was found in 10 nodules (41.6 %). Clinical and imaging follow-up (mean duration 42.2 months, SD ± 34.9, range 2-108) was available in 15 patients with 16 SNNs: no changes in size and echostructure were seen. CEUS can contribute to the diagnosis of SNN when a "punched out" appearance in all vascular phases with or without thin rim enhancement in the very early arterial phase is present in healthy subjects in whom a focal liver lesion is incidentally found. In patients with a history of chronic liver disease or malignancy, US-guided biopsy represents the unavoidable first-line diagnostic modality.ZIEL: Diese multizentrische retrospektive Studie beleuchtet die Befunde des kontrastverstärkten Ultraschalls (CEUS) bei histologisch nachgewiesenen solitären nekrotischen Knoten (SNN) der Leber, einer schlecht verstandenen pathologischen Entität ungewisser Entstehung 22 Patienten (M/F 13/9; mittleres Alter 59,4 Jahre, SD ± 10,7, Bereich 35–81) mit histologischer SNN-Diagnose und CEUS wurden aus den klinischen, bildgebenden und pathologischen Archiven von 7 US-amerikanischen Interventionszentren ausgewählt, von denen jedes Zentrum 1–6 Fälle (Mittelwert 2,8) zur Verfügung stellte SNN waren ein Zufallsbefund bei Gesunden in 10 Fällen (45,5 %), während sie bei der Nachsorge von bekannten extrahepatischen Malignomen in 9 Fällen (41 %) oder von chronischen Lebererkrankungen in 3 Fällen (13,5 %) entdeckt wurden. Die SNNs hatten eine mittlere Größe von 19,3 mm (SD ± 6,5, Bereich 9–40). Im Graustufen-Ultraschall zeigten sich die SNN in 14 Fällen (66,7 %) hypoechogen, in 7 Fällen (29,2 %) „zielähnlich“ und in einem Fall (4,1 %) homogen hyperechogen. Bei der CEUS-Untersuchung erschienen alle Läsionen ohne Kontrastanreicherung („ausgestanztes“ Aussehen) in der arteriellen, portalvenösen und späten Phase nach US-Kontrastmittelinjektion. Ein gleichmäßig dünner Ring mit Hyperenhancement in der frühen arteriellen Phase und Isoenhancement zum umgebenden Parenchym in der portalvenösen und späten Phase wurde bei 10 Knoten (41,6 %) gefunden.Eine klinische und bildgebende Nachbeobachtung (mittlere Dauer 42,2 Monate, SD ± 34,9, Bereich 2–108) stand bei 15 Patienten mit 16 SNNs zur Verfügung. Es wurden keine Veränderungen in Größe und Echostruktur festgestellt. CEUS kann zur Diagnose von SNN beitragen, wenn bei gesunden Probanden, bei denen zufällig eine fokale Leberläsion gefunden wird, ein „ausgestanztes“ Erscheinungsbild in allen vaskulären Phasen mit oder ohne dünnem Randsaum in der sehr frühen arteriellen Phase vorhanden ist. Bei Patienten mit chronischer Lebererkrankung oder einer Tumorerkrankung in der Anamnese ist die US-gestützte Biopsie unweigerlich die First-Line-Diagnostik.

Hepatocellular carcinoma (HCC) is one of the few cancers for which locoregional treatments (LRTs) are included in international guidelines and are considered as a valid alternative to conventional surgery. According to Barcelona Clinic Liver Cancer classification, percutaneous treatments such as percutaneous ethanol injection, radiofrequency ablation and microwave ablation are the therapy of choice among curative treatments in patients categorized as very early and early stage, while transcatheter arterial chemoembolization is considered the better option for intermediate stage HCC. A precise assessment of treatment efficacy and surveillance is essential to optimize survival rate, whereas residual tumor requires additional treatment. Imaging modalities play a key role in this task. Currently, contrast-enhanced computed tomography/magnetic resonance imaging are considered the standard imaging modalities for this purpose. Contrast enhanced ultrasound (CEUS), using second generation contrast agents, plays an increasingly important role in detecting residual disease after LRTs. CEUS is a straightforward to perform, repeatable and cost-effective imaging modality for patients with renal failure or iodine allergies. Due to the ability to focus on single regions, CEUS can also provide high temporal resolution. Moreover, several studies have reported the same or better diagnostic accuracy as contrast-enhanced computed tomography for assessing tumor vascularity 1 mo after LRTs, and recently three-dimensional (3D)-CEUS has been reported as a promising technique to improve the evaluation of tumor response to therapy. Furthermore, CEUS could be used early after procedures in monitoring HCC treatments, but nowadays this indication is still debated, and data from literature are conflicting, especially after transcatheter arterial chemoembolization procedure.

The role of contrast-enhanced ultrasound (CEUS) in interventional ultrasound-guided procedures in the liver has been increasingly recognized. However, little is known about the capability of CEUS for diagnosing complications after liver biopsy and ablation with special regard to postprocedural hemorrhage. The aim of this Pictorial Essay is to present the CEUS features of a wide spectrum of vascular complications (with or without bleeding) and injuries of the surrounding abdominal and chest wall occurring after liver interventional procedures.

Contrast-enhanced ultrasonography (CEUS) plays an important role in the management of patients treated with ablation therapies, in the diagnostic, therapeutic and monitoring phases. Compared to contrast-enhanced computed tomography and contrast-enhanced magnetic resonance imaging, CEUS presents several advantages in imaging HCC, including real time imaging capability, high sensitivity for tumor vascularity, absence of renal toxicity, no ionizing radiation, repeatability of injections, good compliance by the patient and low cost. The purpose of this review is to evaluate the role of CEUS in the management of the patients with HCC treated with ablation therapies and describe how in our protocol CEUS is integrated with the other imaging modalities such as contrast-enhanced computed tomography and contrast-enhanced magnetic resonance imaging.

The present, updated document describes the fourth iteration of recommendations for the hepatic use of contrast enhanced ultrasound (CEUS), first initiated in 2004 by the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). The previous updated editions of the guidelines reflected changes in the available contrast agents and updated the guidelines not only for hepatic but also for non-hepatic applications.The 2012 guideline requires updating as previously the differences of the contrast agents were not precisely described and the differences in contrast phases as well as handling were not clearly indicated. In addition, more evidence has been published for all contrast agents. The update also reflects the most recent developments in contrast agents, including the United States Food and Drug Administration (FDA) approval as well as the extensive Asian experience, to produce a truly international perspective.These guidelines and recommendations provide general advice on the use of ultrasound contrast agents (UCA) and are intended to create standard protocols for the use and administration of UCA in liver applications on an international basis to improve the management of patients.

Fibrolamellar hepatocellular carcinoma (f-HCC) is a rare primary liver tumor. Imaging plays an important role in diagnosis. The aim of this retrospective study was to analyze contrast-enhanced ultrasound (CEUS) features of histologically proven f-HCC in comparison to benign focal nodular hyperplasia (FNH). 16 patients with histologically proven f-HCC lesions and 30 patients with FNH lesions were retrospectively reviewed regarding CEUS features to determine the malignant or benign nature of the focal liver lesions (FLL). Five radiologists assessed the CEUS enhancement pattern and came to a consensus using the EFSUMB (European Federation of Societies for Ultrasound in Medicine and Biology) guideline criteria. Fibrolamellar hepatocellular carcinoma manifested as a single and huge FLL. On CEUS, f-HCC showed heterogeneous hyperenhancement in the arterial phase and hypoenhancement (16/16, 100 %) in the portal venous and late phases (PVLP) as a sign of malignancy. In contrast to the hypoenhancement of f-HCC in the PVLP, all patients with FNH showed hyperenhancement as the most distinctive feature (P 0.01). 8 f-HCC lesions showed a central scar as an unenhanced area (8/16, 50.0 %), which could also be detected in 53.3 % (16/30) of FNH lesions (P 0.05). By analyzing the hypoenhancement in the PVLP, CEUS imaging reliably diagnosed f-HCC as a malignant FLL. CEUS also showed differentiation between f-HCC and FNH lesions, showing similar non-enhanced central scars, whereas f-HCC lesions showed peripheral hyperenhancement in the arterial phase and early washout in the PVLP.ZIEL: Das fibrolamelläre hepatozelluläre Karzinom (f-HCC) ist ein seltener primärer Lebertumor. Die Bildgebung spielt bei der Diagnose eine wichtige Rolle. Ziel dieser retrospektiven Studie war es, die Merkmale im kontrastverstärkten Ultraschall (CEUS) bei histologisch nachgewiesenem f-HCC im Vergleich zur benignen fokalen nodulären Hyperplasie (FNH) zu analysieren. 16 Patienten mit histologisch nachgewiesenen f-HCC-Läsionen und 30 Patienten mit FNH-Läsionen wurden retrospektiv auf CEUS-Merkmale untersucht, um die maligne oder benigne Natur der fokalen Leberläsionen (FLL) zu bestimmen. 5 Radiologen bewerteten das CEUS-Enhancement-Muster und kamen zu einem Konsens unter Verwendung der Kriterien der EFSUMB (European Federation of Societies for Ultrasound in Medicine and Biology) -Richtlinien. Das fibrolamelläre Leberzellkarzinom manifestierte sich als eine einzige und große FLL. Im CEUS zeigte das f-HCC ein heterogenes Hyperenhancement in der arteriellen Phase und ein Hypoenhancement (16/16, 100 %) in der portalvenösen und späten Phase (PVLP) als Marker für Malignität. Im Gegensatz zum Hypoenhancement des f-HCC in der PVLP zeigten alle Patienten mit FNH ein Hyperenhancement als auffälligstes Merkmal (p 0,01). 8 f-HCC-Läsionen zeigten eine zentrale Narbe als Bereich ohne Anreicherung (8/16; 50,0 %), welche auch bei 53,3 % (16/30) der FNH-Läsionen nachgewiesen werden konnte (p 0,05). Durch die Untersuchung des Hypoenhancements in der PVLP konnte die CEUS-Bildgebung f-HCC zuverlässig als maligne FLL diagnostizieren. Außerdem konnte CEUS zwischen f-HCC und FNH-Läsionen differenzieren und zeigte ähnliche zentrale Narben ohne Anreicherung, wobei f-HCC-Läsionen ein peripheres Hyperenhancement in der arteriellen Phase und ein frühes Wash-out in der PVLP zeigten.

Contrast-enhanced ultrasound (CEUS) is an imaging modality applied in a broad field of medical specialties for diagnostic uses, guidance during biopsy procedures and ablation therapies and sonoporation therapy. Appropriate training and assessment of theoretical and practical competencies are recommended before practicing CEUS, but no validated assessment tools exist. This study was aimed at developing a theoretical multiple-choice question-based test for core CEUS competencies and gathering validity evidence for the test. An expert team developed the test via a Delphi process. The test was administered to medical doctors with varying CEUS experience, and the results were used to evaluate test items, internal-consistency reliability, ability to distinguish between different proficiency levels and to establish a pass/fail score. Validity evidence was gathered according to Messick's framework. The final test with 47 test items could distinguish between operators with and without CEUS experience with acceptable reliability. The pass/fail score led to considerable risk of false positives and negatives. The test may be used as an entry test before learning practical CEUS competencies but is not recommended for certification purposes because of the risk of false positives and negatives. publishedVersion

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.

The updated version of the EFSUMB guidelines on the application of non-hepatic contrast-enhanced ultrasound (CEUS) deals with the use of microbubble ultrasound contrast outside the liver in the many established and emerging applications.Die aktualisierte Version der EFSUMB-Leitlinien für die Anwendung von nicht-hepatischem kontrastverstärktem Ultraschall (CEUS) befasst sich mit der Verwendung von Mikrobläschen Ultraschall-Kontrastmitteln außerhalb der Leber in zahlreichen etablierten und neu entstehenden Einsatzbereichen.

This review focuses on the use of contrast-enhanced ultrasonography (CEUS) with SonoVue (Bracco Imaging) for the diagnosis of focal liver lesions (FLLs), guidance during ablative treatment, and follow-up of liver tumors. Multicenter trials have shown that the performance of CEUS for the characterization of FLLs is similar to that of contrast-enhanced computed tomography or contrast-enhanced magnetic resonance imaging. CEUS with SonoVue has been effectively used for guiding the percutaneous treatment of malignant liver tumors that are invisible or poorly visualized in traditional gray-scale ultrasonography. Postprocedural CEUS may be used to detect and retreat residual viable tissue in the same ablative session. The use of CEUS for the assessment of diffuse liver disease is also discussed.

To retrospectively characterize the prevalence and impact of contrast-enhanced ultrasound (CEUS) as a guidance technique for the biopsy of liver target lesions (LTLs) at six interventional ultrasound centers. The six participating centers retrospectively selected all patients in whom biopsy needles were positioned in LTLs during CEUS. The prevalence of CEUS-guided biopsies at each center between 2005 and 2016, contrast agent consumption, procedure indications, diagnostic yield and complications were assessed. Informed consent was obtained for all patients. CEUS-guided biopsy of LTLs was carried out in 103 patients (68 M/35 F, median age: 69 yrs) with 103 liver target lesions (median size: 20 mm) using cutting needles (18 - 20 g) in 94 cases (91.2 %). CEUS-guided biopsy represented 2.6 % (range: 0.8 - 7.7 %) of 3818 biopsies on LTLs carried out at the participating centers. Indications to CEUS-guided biopsy were: a target lesion not visible on non-enhanced US (27.2 %), improvement of conspicuity of the target (33 %), choice of non-necrotic area inside the target (39.8 %). 26 patients (25.2 %) had a previously non-diagnostic cyto-histological exam. The diagnostic accuracy of the technique was 99 %. No major complications followed infusion of contrast agent or biopsy performance. The indications for CEUS-guided biopsy for LTLs are limited, but CEUS can be useful in challenging clinical scenarios, e. g. poorly visualized or invisible lesions or sampling of non-necrotic areas in the target lesions. There is also a potential advantage in using CEUS to guide repeat biopsies after unsuccessful sampling performed using the standard ultrasound technique.ZIEL: Retrospektive Charakterisierung der Prävalenz und der Bedeutung des kontrastverstärkten Ultraschalls (CEUS) als Führungstechnik bei der Biopsie von Leber-Zielläsionen (LTL) in sechs interventionellen Ultraschallzentren. Die sechs teilnehmenden Zentren wählten retrospektiv alle Patienten aus, bei denen Biopsienadeln in den LTLs während des CEUS positioniert waren. Die Häufigkeit der CEUS-gestützten Biopsien an jedem Zentrum zwischen 2005 und 2016, der Kontrastmittelverbrauch, die Indikationen für den Eingriff, der diagnostische Gewinn und Komplikationen wurden beurteilt. Eine Einverständniserklärung wurde für alle Patienten eingeholt. Eine CEUS-gestützte Biopsie der LTL wurde bei 103 Patienten (68 M / 35 F, medianes Alter: 69 Jahre) mit 103 Leber-Zielläsionen (mediane Größe: 20 mm) durchgeführt, wobei in 94 Fällen (91,2 %) Biopsienadeln (18 – 20 g) zum Einsatz kamen. Die CEUS-gestützte Biopsie betrug 2,6 % (Bereich: 0,8 – 7,7 %) der 3818 LTL-Biopsien, die in den teilnehmenden Zentren durchgeführt wurden. Indikationen für eine CEUS-gestützte Biopsie waren: Eine im konventionellen US nicht sichtbare Zielläsion (27,2 %), eine Verbesserung der Auffälligkeit des Ziels (33 %), die Auswahl eines nicht-nekrotischen Bereichs im Ziel (39,8 %). Bei 26 Patienten (25,2 %) wurde zuvor eine nicht-diagnostische zytologische Untersuchung durchgeführt. Die diagnostische Genauigkeit der Methode betrug 99 %. Es traten keine größeren Komplikationen nach Infusion des Kontrastmittels oder bei Durchführung der Biopsie auf. Die Indikationen für die CEUS-gestützte Biopsie bei LTLs sind begrenzt, aber CEUS kann in schwierigen klinischen Szenarien nützlich sein, zum Beispiel bei schlecht darzustellenden oder unsichtbaren Läsionen oder bei Probenentnahme in nicht-nekrotischen Bereichen der Zielläsionen. Einen möglichen Nutzen besteht für den Einsatz von CEUS bei der Führung von Wiederholungsbiopsien, wenn die Probennahme bei Anwendung der Standard-Ultraschalltechnik erfolglos war.

The aim of this article is to provide an inventory of the use of contrast-enhanced ultrasound (CEUS) in relation to percutaneous interventional procedures. The article is structured into a systematic literature review followed by a clinical part relating to percutaneous CEUS-guided procedures. A literature search identified 3109 records. After abstract screening, 55 articles were analyzed and supplemented with pictorial material to explain the techniques. In conclusion, the best-evidenced indications for CEUS-guided interventions are biopsy and ablation of inconspicuous or B-mode-invisible tumors, intraprocedural ablation control and follow-up, as well as percutaneous transhepatic cholangiography and drainage procedures.

The present, updated document describes the fourth iteration of recommendations for the hepatic use of contrast-enhanced ultrasound, first initiated in 2004 by the European Federation of Societies for Ultrasound in Medicine and Biology. The previous updated editions of the guidelines reflected changes in the available contrast agents and updated the guidelines not only for hepatic but also for non-hepatic applications. The 2012 guideline requires updating as, previously, the differences in the contrast agents were not precisely described and the differences in contrast phases as well as handling were not clearly indicated. In addition, more evidence has been published for all contrast agents. The update also reflects the most recent developments in contrast agents, including U.S. Food and Drug Administration approval and the extensive Asian experience, to produce a truly international perspective. These guidelines and recommendations provide general advice on the use of ultrasound contrast agents (UCAs) and are intended to create standard protocols for the use and administration of UCAs in liver applications on an international basis to improve the management of patients.

Thermal ablation is increasingly being utilised in the treatment of primary and metastatic liver tumours, both as curative therapy and as a bridge to transplantation. Recent advances in high-powered microwave ablation systems have allowed physicians to realise the theoretical heating advantages of microwave energy compared to other ablation modalities. As a result there is a growing body of literature detailing the effects of microwave energy on tissue heating, as well as its effect on clinical outcomes. This article will discuss the relevant physics, review current clinical outcomes and then describe the current techniques used to optimise patient care when using microwave ablation systems.

The aim of this study was to compare the performance of a microwave ablation (MWA) apparatus in preclinical and clinical settings.The same commercial 2.45 GHz MWA apparatus was used throughout this study. In total 108 ablations at powers ranging from 20 to 130 W and lasting from 3 to 30 min were obtained on ex vivo bovine liver; 28 ablations at 60 W, 80 W and 100 W lasting 5 and 10 min were then obtained in an in vivo swine model. Finally, 32 hepatocellular carcinomas (HCCs) and 19 liver metastases in 46 patients were treated percutaneously by administering 60 W for either 5 or 10 min. The treatment outcome was characterised in terms of maximum longitudinal and transversal axis of the induced ablation zone.Ex vivo ablation volumes increased linearly with deposited energy (rFor the selected MW ablation device, ex vivo data on bovine liver was more predictive of the actual clinical performance on liver malignancies than an in vivo porcine model. Equivalent MW treatments yielded a significantly different response for HCC and metastases at higher deposited energy, suggesting that outcomes are not only device-specific but must also be characterised on a tissue-by-tissue basis.

Purpose: To evaluate the safety and intermediate-term efficacy of percutaneous microwave ablation (MWA) in primary and secondary liver tumors using a third generation MWA device, under ultrasound guidance. Patients and methods: Sixty-two patients (median age 74 years, 73 % males) with 69 liver tumors were enrolled in this prospective observational study. Forty-seven patients (76 %) had hepatocellular carcinoma (HCC) and 15 (24 %) metastases. Median follow-up was 3.6 years. Results: Median tumor diameter at contrast enhanced computed tomography was 23 mm (I–III quartiles, 18 – 31 mm). All procedures were performed percutaneously using a 2.45 GHz generator. Median ablation time was 10 minutes (I–III quartiles, 10 – 14 minutes). A single percutaneous antenna insertion was performed for 56/69 (81 %) of the tumors. Technical success was obtained in all tumors. Primary efficacy at 24 hours was achieved in 68/69 (99 %) tumors. The overall one-year cumulative local tumor progression rate was 15.1 % (95 % CI, 7.7 – 24.8 %) with no significant difference between HCC and metastases (p = 0.26). There was one procedure-related mortality (1.6 %) and one major bleeding (1.6 %). Conclusion: Microwave ablation is a valid option for thermal ablation of HCC and liver metastases with comparable complication rate to other local ablative procedures.

In 2007 the Italian National Institute of Health issued Guidelines for the use of diagnostic imaging techniques in the detection and the characterization of focal liver lesions. Since the publication of these guidelines in 2008, several studies relating to this topic have been published. Thus, we felt the need to assess whether interval research and new advancements in diagnostic imaging have yielded new evidence that should modify the recommendations that were previously issued. The literature search confirmed the appropriateness of the current guidelines. Although most modalities did not show substantial changes, interval introduction of DW-MRI is a valuable technique with a high diagnostic accuracy in the detection and characterization of FLLs, and its sensitivity is higher when combined with MRI. Abbreviations: AASLD: American Association for the Study of Liver Disease; CE-IOUS: contrast-enhanced intraoperative US; CEUS: contrast-enhanced ultrasound; CRLM: colorectal liver metastasis; DW-MRI: diffusion weighted MRI; EOB-MRI: gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid MRI; FLLs: focal liver lesions; HCC: hepatocellular carcinoma; LR+: positive likelihood ratio; LR-: negative likelihood ratio; NPV: negative predictive value; PET: positron emission tomography; PPV: positive predictive value; RF: radiofrequency; TACE: transarterial chemoembolization

The updated version of the EFSUMB guidelines on the application of non-hepatic contrast-enhanced ultrasound (CEUS) deals with the use of microbubble ultrasound contrast outside the liver in the many established and emerging applications.Die aktualisierte Version der EFSUMB-Leitlinien für die Anwendung von nicht-hepatischem kontrastverstärktem Ultraschall (CEUS) befasst sich mit der Verwendung von Mikrobläschen Ultraschall-Kontrastmitteln außerhalb der Leber in zahlreichen etablierten und neu entstehenden Einsatzbereichen.

The aim of this article is to provide an inventory of the use of contrast-enhanced ultrasound (CEUS) in relation to percutaneous interventional procedures. The article is structured into a systematic literature review followed by a clinical part relating to percutaneous CEUS-guided procedures. A literature search identified 3109 records. After abstract screening, 55 articles were analyzed and supplemented with pictorial material to explain the techniques. In conclusion, the best-evidenced indications for CEUS-guided interventions are biopsy and ablation of inconspicuous or B-mode-invisible tumors, intraprocedural ablation control and follow-up, as well as percutaneous transhepatic cholangiography and drainage procedures.

Objective: We described an impressive cluster of hepatitis C in a single family. Of nine members of the family, six - the mother and five daughters - were affected by chronic hepatitis, hepatitis C virus (HCV) genotype 1b, of which two were co-infected with hepatitis B virus (HBV). Sharing a non-disposable injection equipment for intramuscular medical care was the most likely route of contagion. Twenty years after the first observation, we performed a follow up of this family. Methods: The clinical history was updated, and the members of the family underwent a clinical evaluation, extensive liver laboratory tests, and whole serology for hepatitis C and B. Protein chain reaction for HCV RNA was performed when indicated. The eight spouses of the offspring and their eight children underwent the same evaluation. Results: The main findings of this study are the favourable outcome of the two members of the family mono-infected by HCV, treated with peginterferon and ribavirin (sustained response and free of liver disease), in contrast with the ominous outcome of the two members co-infected with HCV and HBV, who evolved to decompensated cirrhosis, with hepatocellular carcinoma in one case, ultimately leading to death. A further feature is the absence of transmission of HCV to the spouses and to the third generation of children of this family, consistent with the assumption that sexual and vertical transmission is unlikely. Conclusions: A thorough epidemiological investigation of the two first generations of this family, the study of their spouses and children, and the twenty years of follow up provided a strong presumption that the infection with HCV had occurred within this family through the promiscuous use of the same inadequately sterilized glass syringe for intramuscular therapies, as was a common practice during the fifties and sixties worldwide and still is in some part of the world.

Liver metastases often exhibit a hypervascular halo during the arterial phase of contrast-enhanced ultrasonography (CEUS). This finding has no correlates on baseline gray-scale imaging, and it has never been characterized. The aim of this study was to identify the features of this halo and determine whether it should be included in the ablation volume during thermal ablation procedures.We prospectively enrolled 25 patients referred to our department for thermal ablation of liver metastases. Before treatment all patients underwent CEUS, and the maximum diameter of the metastatic lesion was measured before administration of the ultrasound contrast agent and during the arterial and portal venous phases of the contrast contrast-enhanced study. Maximum diameters in the different vascular phases were compared with the Turkey-Kramer test. Two biopsies were obtained from each lesion with a 21-gauge needle: 1) one from the center of the metastasis to confirm the diagnosis and 2) one from the hypervascular peripheral halo identified in the arterial phase at CEUS.The mean (±standard deviation) maximum lesion diameter was 2.67 ± 1.2 cm before contrast agent injection, 3.50 ± 1.4 cm during the arterial phase, and 2.71 ± 1.2 cm during the venous phase. The difference between maximum diameters measured before contrast enhancement and in the arterial phase was highly significant (mean: 0.84 ± 0.45 cm, p 0.0001). Histological examination of halo specimens revealed inflammatory infiltrates with no evidence of tumor infiltration in 24/25 (96%) cases and normal hepatic parenchymal tissue in the 25th specimen.The hypervascular halo surrounding liver metastases during the arterial phase of CEUS represents a chronic inflammatory infiltrate, not tumor infiltration. However, since chronic inflammation appears to promote neovascularization and the production of tumoral growth factors, it seems wise to include the hypervascular halo in the intended-to-treat volume when planning the ablation procedure.Sommario INTRODUZIONE: All’ecografia con Mezzo di Contrasto (CEUS) dei tumori secondari epatici si evidenzia spesso un alone periferico ipervascolare, che non ha corrispondenza sull’immagine ecografica di base e non è ancora stato caratterizzato istologicamente. Lo scopo dello studio è di caratterizzare tale alone al fine di determinare se sia necessario includerlo nel volume di necrosi pianificato. MATERIALI E METODI: Questo studio prospettico ha incluso 25 pazienti inviati per terapia termo-ablativa di tumori secondari epatici. Prima del trattamento tutti i pazienti sono stati sottoposti a CEUS. Il diametro maggiore della lesione è stato determinato: pre-contrasto, durante la fase arteriosa e durante la fase venosa portale. I diametri delle lesioni pre e post-contrasto sono stati confrontati mediante il test di Turkey–Kramer. Due campioni bioptici sono stati prelevati con ago 21-gauge e analizzati istologicamente: 1) uno dalla zona centrale del tumore e 2) uno dall’alone periferico ipervascolare, identificato alla CEUS solamente nella fase arteriosa. RISULTATI: Il diametro massimo medio delle lesioni è risultato (±deviazione standard): 2,67 ± 1,2 cm pre-contrasto; 3,50 ± 1,4 cm in fase arteriosa; 2,71 ± 1,2 cm in fase venosa. La differenza media tra il diametro massimo pre-contrasto e in fase arteriosa è risultata di 0,84 ± 0,45cm (p0,0001). All’esame istologico, 24/25 campioni (96%) hanno dimostrato flogosi senza evidenza di tumore microscopico. DISCUSSIONE: L’alone ipervascolare periferico è costituito da infiltrato infiammatorio, non da tessuto tumorale. Esistono evidenze in letteratura che l’infiammazione cronica promuova la neovascolarizzazione e la produzione di fattori di crescita per le cellule neoplastiche. Sembra quindi opportuno includere completamente l’alone ipervascolare periferico evidente alla CEUS nel volume di termo-ablazione.

Microwave thermal tumor ablation is an expanding treatment option to obtain local control of focal liver tumors with complication rates similar to other thermal ablation techniques. We report two cases of portal vein segmental branch thrombosis identified by US and CT imaging 40 days following percutaneous microwave ablation. One patient was treated for hepatocellular carcinoma in a cirrhotic liver, the other was treated for metastatic colon cancer in an otherwise normal liver. Both patients were clinically asymptomatic when the thromboses were identified. Evaluation of the vascular anatomy surrounding the tumor and of risk factors for development of portal vein thrombosis is critical when selecting patients for microwave tumor ablation.

PURPOSE: To retrospectively assess the local control and intermediate- and long-term survival of patients with liver metastases from breast cancer who have undergone percutaneous ultrasonography (US)-guided radiofrequency (RF) ablation. MATERIALS AND METHODS: This study was approved by the hospital ethics committee, and all patients provided written informed consent. RF ablation was used to treat 87 breast cancer liver metastases (mean diameter, 2.5 cm) in 52 female patients (median age, 55 years). Inclusion criteria were as follows: fewer than five tumors, maximum tumor diameter of 5 cm or smaller, and disease either confined to the liver or stable with medical therapy. Forty-five (90%) of 50 patients had previously undergone chemotherapy, hormonal therapy, or both, and had no response or an incomplete response to the treatment. Contrast material-enhanced computed tomography and US were performed to evaluate complications and technical success and to assess for local tumor progression during follow-up. The Kaplan-Meier method was used to assess survival, and results were compared between groups with a log-rank test. Cox regression analysis was used to assess independent prognostic factors that affected survival. RESULTS: Complete tumor necrosis was achieved in 97% of tumors. Two (4%) minor complications occurred. Median time to follow-up from diagnosis of liver metastasis and from RF ablation was 37.2 and 19.1 months, respectively. Local tumor progression occurred in 25% of patients. New intrahepatic metastases developed in 53% of patients. From the time of first RF ablation, overall median survival time and 5-year survival rate were 29.9 months and 27%, respectively. From the time the first liver metastasis was diagnosed, overall median survival time was 42 months, and the 5-year survival rate was 32%. Patients with tumors 2.5 cm in diameter or larger had a worse prognosis (hazard ratio, 2.1) than did patients with tumors smaller than 2.5 cm in diameter. CONCLUSION: Survival rates in selected patients with breast cancer liver metastases treated with RF ablation are comparable to those reported in the literature that were achieved with surgery or laser ablation

The chapter considers the principles, the techniques, the results of PEI for treating cirrhotic patients with HCC, and its current indications compared to those of RF, which is now considered the gold standard.

Objectives Direct puncture of subcapsular hepatocellular carcinoma (HCC) for tumor ablation has been considered high risk due to a perceived increased incidence of hemorrhage or tumor seeding. The purpose of this retrospective multicenter study was to identify the rate of tumor seeding, hemorrhage and local tumor progression (LTP) associated with direct puncture radiofrequency (RF) and microwave (MW) ablation of subcapsular HCC. Methods A multicenter, retrospective review of direct-puncture RF and MW performed on subcapsular HCC was conducted. Complications and local tumor progression were documented. Data was analyzed using Kaplan–Meier and log-rank tests. Results The study group consisted of 60 cirrhotic patients (M/F = 43/17; mean age 69.6 years) with 67 subcapsular HCC (mean diameter 2.3 cm ± 1.0 cm) that were directly punctured for RF (n = 40) or MW (n = 27) under ultrasound (US) guidance. The mean follow-up period was 30.8 months. There were no hemorrhagic complications. The overall LTP rate was 13.4%. There was one case of tumor tract seeding in a patient who had undergone a percutaneous biopsy two weeks prior to RF. Conclusions Thermal ablation of HCC by direct puncture appears safe and effective. There were no cases of intraperitoneal hemorrhage, and tumor seeding was seen in a single case in which a preceding percutaneous biopsy had been performed.

The tumors of the kidney are around the 3% of the neoplasia in adult patients and, at the postmortem examination, the renal neoplasias has a frequency of 1/300 for tumors diameter of 1 to 2 cms. In the treatment of the small neoplasias, techniques of nephron sparing and enucleation are used. These techniques have shown the same therapeutic effectiveness of the radical nephrectomy in patients with tumors smaller than 4 centimeters, with reduction of morbidity. However, there are few clinical situation in which the surgery has a high risk: patients with solitary kidney, chronic renal failure, multiple localizations involving also contralateral kidney, in patients with other malignancies and in von Hippel-Lindau Syndrome. Recently, percutaneous mininvasive techniques have been applied (ex. thermoablation): these techniques allow to reduce the duration of general anesthesia, they offer the possibility to use spinal anaesthesia (besides deep sedation and general anaesthesia) with reduction in mortality during surgery. The most commonly used among interstitial therapies is the radiofrequency (RF), which changes electromagnetic waves into heat. RF used both tomography and ultrasound-guided. The latter is the most recommended because it allows to follow the procedure in real-time. The treatment of renal tumors with RF, in which surgery is inadvisable, is safe and effective especially in peripheral and/or exophytic lesions lower than 4 cm. However the larger tumors can also be treated successfully with combined therapy or multiple sessions.

Image-guided percutaneous ablation techniques are increasingly being used for the treatment of malignant tumors of the liver and kidney. Contrast enhanced ultrasound (CEUS) is a real-time dynamic imaging technique that plays an important role in the pre-, intra-, and post-procedural management of these patients. This review will focus on the role of CEUS in the evaluation of patients undergoing treatment with percutaneous ablation for hepatic or renal tumors.

The purpose of this study was to compare the efficacy of contrast-enhanced pulse inversion harmonic imaging with contrast-enhanced power Doppler sonography and helical CT to determine incomplete local treatment after radiofrequency ablation in patients with hepatocellular carcinoma.Thirty-five consecutive patients (24 men and 11 women; mean age, 64 years) with 43 hepatocellular carcinomas (3.6 +/- 1.1 cm) were treated using internally cooled radiofrequency ablation therapy. Therapeutic response was evaluated at 4 months with dual-phase contrast-enhanced helical CT, conventional power Doppler Sonography, and pulse inversion harmonic imaging using a sonographic contrast agent (SH-508). CT and sonographic studies were reviewed separately in random order by four radiologists at different consensus conferences. Sensitivity and specificity of the sonographic methods were determined using CT as a gold standard and results were compared using the McNemar test.CT examinations identified residual tumor in 12 lesions (27.9%). Although conventional contrast-enhanced power Doppler sonography identified residual viable tumor foci in four incompletely treated lesions (9.3%), contrast-enhanced pulse inversion harmonic imaging identified residual tumoral enhancement in 10 lesions (23.3%). Thus, the sensitivity of pulse inversion harmonic imaging (83.3%) was significantly greater (p0.05) for detecting residual nonablated tumor compared with conventional contrast-enhanced power Doppler sonography.Our study suggests that contrast-enhanced pulse inversion harmonic imaging may enable the detection of residual nonablated tumor in more cases than contrast-enhanced power Doppler sonography and may ultimately prove to be a useful adjunct for percutaneous ablation therapies. Nevertheless, contrast-enhanced axial imaging (CT or MR imaging) is currently the most sensitive test for managing thermal ablation for patients with hepatocellular carcinoma.

Image-guided tumor ablation has become a well-established hallmark of local cancer therapy. The breadth of options available in this growing field increases the need for standardization of terminology and reporting criteria to facilitate effective communication of ideas and appropriate comparison among treatments that use different technologies, such as chemical (eg, ethanol or acetic acid) ablation, thermal therapies (eg, radiofrequency, laser, microwave, focused ultrasound, and cryoablation) and newer ablative modalities such as irreversible electroporation. This updated consensus document provides a framework that will facilitate the clearest communication among investigators regarding ablative technologies. An appropriate vehicle is proposed for reporting the various aspects of image-guided ablation therapy including classification of therapies, procedure terms, descriptors of imaging guidance, and terminology for imaging and pathologic findings. Methods are addressed for standardizing reporting of technique, follow-up, complications, and clinical results. As noted in the original document from 2003, adherence to the recommendations will improve the precision of communications in this field, leading to more accurate comparison of technologies and results, and ultimately to improved patient outcomes. Online supplemental material is available for this article .

To retrospectively assess the diagnostic accuracy of immediate post-procedural CEUS, 24-h CEUS, and 24-h CT in verifying the effectiveness of thermal ablation of liver tumors ablation, using the combined results of 3-month post-procedure CEUS and MDCT as the reference standard.From our database, we selected patients who had immediate post-procedural CEUS and 24-h CEUS and MDCT examinations after undergoing thermal ablation of a liver tumor between January 2009 and March 2010. The study population consisted of 53 subjects and 55 tumors (44 HCC and 11 metastasis) were evaluated. Thirty-seven tumors were treated with radiofrequency and 18 with microwave ablation. Post-procedural CEUS, 24-h CEUS and MDCT, and 3-month follow-up CEUS and MDCT images were blindly reviewed by two radiologists, who measured the size of the ablation area on the post-procedural and 24-h studies. They also evaluated the ability of each of these three index tests to predict the outcome (residual tumor vs. no residual tumor) using imaging studies done at the 3-month follow-up as the reference standard.Mean tumor diameter on preablation CEUS (the day before treatment) was 20 ± 9 mm. Mean diameter of the necrotic area was 29 ± 9 mm on post-procedural CEUS, 34 ± 11 mm on 24-h CEUS, and 36 ± 11 mm on 24-h MDCT. Diameters of the necrotic area (mean and maximum) on post-procedural CEUS were significantly smaller than those measured on 24-h CEUS or 24-h MDCT, which were not significantly different. For predicting the presence of residual tumor at the 3-month follow-up, post-procedural CEUS, 24-h CEUS, and 24-h MDCT displayed sensitivity of 33%, 33%, and 42%; specificity of 92%, 97%, and 97%; negative predictive value of 84%, 85%, and 83%. The accuracy parameters of these three imaging modalities were not significantly different from one another.In patients undergoing thermal ablation for liver tumors, the immediate post-procedural CEUS seems comparable to 24-h CEUS and MDCT in terms of detecting residual disease.Determinare retrospettivamente l’accuratezza diagnostica nella valutazione di efficacia delle ablazioni di tumori epatici della CEUS eseguita al termine della procedura ablativa, della CEUS e della la tomografia computerizzata multi-detettore (TCMD) eseguite a 24 ore, utilizzando la CEUS e TCMD a 3 mesi di follow-up come standard di riferimento.Abbiamo selezionato dal nostro data base i pazienti sottoposti a CEUS subito dopo una procedura di ablazione e a CEUS e TCMD dopo 24 ore tra gennaio 2009 e marzo 2010. Il campione era composto da 53 soggetti in cui abbiamo valutato 55 lesioni (44 HCC e 11 metastasi). Trentasette lesioni sono state trattate con ablazione a radiofrequenza, 18 mediante microonde. La CEUS post-trattamento, la CEUS e la TCMD eseguite a 24 ore, e la CEUS e la TCMD eseguite a tre mesi di follow-up sono state rivalutate in cieco da due radiologi. Abbiamo confrontato tra loro le dimensioni della termoablazione misurate alla CEUS post-procedura, alla CEUS e alla TCMD eseguite a 24 ore. Abbiamo calcolato l’accuratezza diagnostica della CEUS post-procedura, della CEUS e della TCMD a 24 ore valutando la capacità di ogni metodica nel rilevare il tessuto vitale residuo utilizzando come standard di riferimento il follow-up a 3 mesi (TCMD e CEUS combinate).Il diametro medio del tumore alla CEUS il giorno prima del trattamento era di 20 ± 9 mm. Il diametro medio della necrosi ottenuta è di: 29 ± 9 mm alla CEUS post-trattamento, 34 ± 11 mm alla CEUS a 24 ore e 36 ± 11 mm alla TCMD a 24 ore. Il diametro medio ed il diametro massimo dell’area di necrosi misurati alla CEUS post-trattamento rispetto alla CEUS o alla TCMD eseguite a 24 ore sono risultati significativamente inferiori. La differenza tra le dimensioni dell’area di necrosi misurate alla CEUS e alla TCMD a 24 ore non è significativa. La CEUS post-trattamento, la CEUS a 24 ore e la TCMD a 24 ore hanno dimostrato i seguenti parametri di accuratezza diagnostica nell’individuare il tumore residuo rispetto al follow-up: sensibilità, 33%, 33%, 42%; specificità, 92%, 97%, 97%; valore predittivo negativo 84%, 85% and 83%. La differenza tra i parametri di accuratezza diagnostica delle tre metodiche non è risultata significativa.L’accuratezza diagnostica della CEUS post-trattamento nell'individuare tessuto tumorale residuo dopo ablazione di tumori epatici è comparabile a quella della CEUS e della TCMD a 24 ore.

Purpose To compare the accuracy of immediate CEUS with results of 24-h CEUS and MDCT in early evaluation of liver tumors following thermal ablation, using the combined results of a 3 month follow-up MDCT and CEUS as a reference standard. Subjects and methods From our database, we selected patients who underwent a thermal ablation immediately followed by CEUS (within 5–10 min) between February 2009 and February 2011. There were 92 patients (median age 73 years), two of whom had repeat ablation during the study period for a total of 94 tumors. Sixty tumors were treated with radiofrequency and 34 with microwave ablation. All patients underwent CEUS and CT examinations at 24 h. For patients with more than one treated tumor in the same session, the lesion imaged post-procedural and at 24-h with CEUS in all vascular phases was selected. All measurements of the necrotic zone, as an avascular zone, were performed during the portal-venous phase. Immediate post-procedural CEUS and 24 h CEUS and MDCT were blindly reviewed by two radiologists. One radiologist blindly reviewed the follow-up imaging. The mean diameters of the necrotic zone at post-procedural CEUS, and CEUS and MDCT at 24 h were compared and diagnostic accuracy to detect residual tumor calculated for each index tests compared to 3-months follow-up imaging. Results The mean diameter of the necrotic zone was: 29 ± 9 mm at post-procedural CEUS, 34 ± 10 mm at 24 h CEUS and 35 ± 11 mm at 24 h MDCT. Mean diameter of the necrotic zone was significantly smaller at post-procedural CEUS compared to either CEUS or MDCT at 24 h (p With a 95% confidence interval, the sensitivity was 25% (11–47%) for immediate CEUS, 20% (8–42%) for CEUS at 24-h, and 40% (22–61%) for CT at 24-h. Specificity was 96% (89–99%) for immediate CEUS, 97% (91–99%) for CEUS at 24-h, and 97% (91–99%) for CT at 24-h. Conclusions Diagnostic accuracy of post-procedural CEUS in early evaluation of liver tumors following thermal ablation is comparable to both CEUS and MDCT performed at 24 h. Therefore, post-procedural CEUS can be used to detect and retreat residual viable tissue in the same ablation session.

To develop guidelines for the noninvasive imaging assessment of focal liver lesions comparing different imaging modalities focused on (i) evaluating the imaging techniques in terms of (a) diagnostic accuracy; (b) role in the management of oncologic patients; (c) follow-up of benign lesions; and (ii) developing standard procedure for their use in patients with focal liver lesions that require targeted diagnostic characterization.An explicit search strategy was used to conduct a systematic review of the literature in the English language from January 2000 to October 2007; the search covered PubMed, Embase, Pascal, SciSearch, and Cochrane Library databases. A panel of experts evaluated the selected studies and conveyed their view.The online search yielded 4960 titles and abstracts from which 176 studies were considered suitable for the final adherence-to-guidelines topic evaluation. An evidence grading system was not used as the guideline topic and the heterogeneity of the collected data did not fit with the currently used hierarchy of evidence. A panel of experts formulated several recommendations with grade and level which were expressed narratively and nonschematically.The recommendations reported in the study are based on an extensive literature evaluation and were developed by considering the appropriateness of the choice of the imaging techniques while noninvasively detecting and characterizing focal liver lesions.

Purpose To evaluate the damage caused by microwave ablation to vessels inside and outside the ablation zone in an in vivo swine model. Materials and Methods Four pigs underwent microwave liver ablation with a 2.45-GHz generator and a 14-gauge water-cooled antenna with a miniature choke. Each animal underwent four 15-minute microwave ablations (two at 40 W, two at 60 W). Mean minimum and maximum diameters of ablation areas were calculated on gross pathologic and histologic examination. At minimum, a whole-mount section and two to four specimens were obtained from each ablation and stained with hematoxylin and eosin. Specimens were analyzed to verify the presence of damaged vessels in and outside the ablation area. Results Mean ablation diameters at gross pathologic examination, including the hemorrhagic halo, were 3.1 cm ± 0.5 at 40 W and 3.6 cm ± 1.1 at 60 W. All ablation zones presented a characteristic pattern consisting of three concentric zones: (i) a central area consisting of coagulative necrosis (mean maximum diameter, 8.5 mm ± 2.6), (ii) a larger area characterized by irreversibly damaged hepatocytes (mean maximum thickness, 11.7 mm ± 3.4), and (iii) a hemorrhagic halo. Twenty-one veins outside the ablation zone were evaluated (mean diameter, 5.6 mm), three of which (14%) showed diffuse endothelial damage. All three represented a continuation of a portal vein within the ablation area. Conclusions In a small percentage of microwave ablation cases, endothelial damage can extend from a portal vessel included in the ablation zone to a segment of the vessel situated outside the ablation zone. Further investigation of the clinical significance of this finding is needed.

We evaluated the ability of one-month follow-up contrast-enhanced ultrasound (CEUS) with second-generation contrast agent in monitoring radio frequency ablation (RFA) and transcatheter arterial chemoembolization (TACE) treatments of hepatocellular carcinoma (HCC). One-hundred forty-eight HCCs were studied using CEUS: 110 nodules were treated with RFA [41/110 RFA were performed using a pretreatment and an immediate postablation evaluation using CEUS (group 1); 69/110 using only US guidance (group 2)] and 38 nodules treated with TACE. For statistical analysis, McNemar test was used. Overall complete response was observed in 107/148 nodules (92/110 treated with RFA and 15/38 with TACE). A better rate of complete response was found in group 1 compared to group 2 (92.7% vs. 78.3%). In RFA treatment, CEUS showed a sensitivity of 83.3% and a specificity of 100% (diagnostic accuracy of 97%) using MDCT as reference standard with no statistical difference (p > 0.05). CEUS detected all cases of incomplete response in HCC treated with TACE using angiography as reference standard (diagnostic accuracy 100%). We recommend assessing residual intratumoral flow on CEUS during RFA procedure to determine the necessity of immediate additional treatment. In case of positive CEUS results, HCC treated with TACE should be considered still viable.

Human brucellosis commonly involves the liver and manifests as nonspecific or granulomatous hepatitis. Although the development of a brucellar hepatic abscess is rare, it can be difficult to accurately diagnose given that histopathologic analysis is often not diagnostic, and the bacterium is seldom isolated from pus cultures. Therefore, serologic tests and imaging play an important role in the diagnosis of a brucellar abscess. The characteristics of a brucellar abscess on conventional ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) have been reported previously. 1,2 However, to the best of our knowledge, the features of a brucellar hepatic abscess on contrast-enhanced ultrasonography (CEUS) have not been described previously. © 2008 by the American Institute of Ultrasound in Medicine.

OBJECTIVE. The purpose of this study was to assess, with contrast-enhanced CT or MRI as the reference imaging technique, the diagnostic performance of low-mechanical-index contrast-enhanced sonography in detecting local tumor progression after percutaneous radiofrequency ablation of renal tumors. Materials AND METHODS. Twenty-nine patients with 30 renal tumors (18 men, 11 women; mean age, 73 years; range, 53–83 years) underwent percutaneous radiofrequency ablation at a single center between March 1998 and January 2007. The imaging follow-up schedule was both contrast-enhanced sonography and CT or MRI 4 months after completion of treatment and every 4 months for the first year. Thereafter, the follow-up schedule was contrast-enhanced sonography every 4 months with CT or MRI every 8 months. The chi square test with Yates correction was used to evaluate positive and negative predictive values and accuracy. RESULTS. One patient was scheduled to undergo surgical resection, and another patient was lost to follow-up. Twenty-seven patients with 28 renal tumors participated in follow-up. The concordance between contrast-enhanced sonographic and CT or MRI findings was 100% for 27 of 28 tumors (96.4%) that had a hypervascular pattern before treatment. In the case of the tumor that was hypovascular at imaging performed before percutaneous radiofrequency ablation, local tumor progression was missed at contrast-enhanced sonography. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of contrast-enhanced sonography were 96.6%, 100%, 100%, 95.8%, and 98.1%. CONCLUSION. Contrast-enhanced sonography is an effective alternative to CT and MRI in the follow-up of renal tumors managed with percutaneous radiofrequency ablation.

Le terapie interstiziali sono largamente utilizzate per il trattamento dei tumori epatici primitivi e secondari [1, 2]. Si sono infatti dimostrate delle valide alternative terapeutiche nei pazienti affetti da tumori epatici primitivi o secondari, non eleggibili per la chirurgia, con significativa riduzione della mortalita e morbilita.La radiofrequenza (RF) e fra queste la piu diffusa, e negli ultimi 5 anni e stata utilizzata su circa 5.000 lesioni epatiche con l’approvazione della Food and Drug Administration (FDA) [3]. Le sue applicazioni sono state ampliate grazie all’efficacia dimostrata sui tumori del fegato, coinvolgendo altri organi e strutture quali polmone [4], rene [5], tiroide [6], mammella [7], osso [8], prostata [9].

The purposes of this study were to assess the feasibility of a sonographic training program at a district hospital in a developing country and to evaluate the effect of the program on public health care services.A sonographic training program is being conducted on Pemba Island, Tanzania. A maximum of 10 trainees participate in the program. Courses in sonography conducted by European physicians are scheduled every 4 months for 2 consecutive weeks each time. The sonographic training program lasts 5 years and is divided into three stages in which basic, advanced, and specialized courses are organized. At the end of every course, the trainees take a multiple-choice test (score, 1-10) and a practical test with patients (score, 1-5). To advance to the next stage, a trainee needs a score of at least 7 on the theory test and at least 3 on the practical.Three courses have been completed. The total mean scores on the multiple-choice test were 7.4 (range, 6.5-9) at the end of the first course, 7.3 (range, 6.5-8.5) at the end of the second course, and 6.2 (range, 4.0-9.5) at the end of the third course. A shortage of electricity hindered the practical test after the first and second courses. At the end of the third course, the total mean score on the practical was 3.5 (range, 1.5-5.0). Seven of 10 trainees were admitted to the second year of the sonographic training program. The mean monthly hospital earnings during the three-course period were 673,200 Tanzanian shillings.Sonography is an affordable technology for developing countries. Training in sonography should be included in the planning of long-term projects in which multiple access and feedback are provided in the same area.

Radiofrequency ablation (RFA) is currently indicated for the treatment of primary and metastatic hepatic malignancies. Real-time ultrasound (US) is generally used during the procedure to guide electrode placement, but for evaluating the results of treatment, contrast-enhanced computed tomography and magnetic resonance imaging have traditionally been considered more effective. This view has changed, however, with the recent development of contrast-enhanced ultrasound (CEUS) (eg, using sulfur hexafluoride microbubbles), which can provide valuable information on the effects of RFA more rapidly and economically than computed tomography or magnetic resonance imaging without exposing the patient to ionizing radiation. In our center, CEUS is performed in patients with liver tumors before and immediately after RFA, in selected cases during the procedure as well, and in the follow-up. Between January 2003 and June 2005, we performed CEUS on 350 patients scheduled for RFA of primary or metastatic liver tumors. In 14 (13.4%) of the 96 patients whose disease was metastatic, CEUS revealed lesions that had been missed on the conventional US examination. In most of these cases, the result was a more complete treatment performed under CEUS guidance. In the remaining 2 (14%) of 14, the results of the examination allowed us to avoid subjecting the patient to useless treatment. In our experience, the use of CEUS also improved the management and follow-up of patients undergoing interstitial therapy.

Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world, and it represents more than 5% of all cancers (1). It usually coexists with underlying chronic liver disease, and according to the stage, one disease will prevail over the other. The stage of HCC at the time of diagnosis is very important to decide the type of treatment—possibly curative when the diagnosis is early, palliative or no treatment when the diagnosis is late.

Percutaneous ethanol injection therapy (PEIT) is one of the most widely used local procedures to treat hepatocellular carcinoma (HCC). Local-regional therapies are specific ablation modalities that introduce a damaging agent directly into the neoplastic tissue percuta-neously. These techniques are capable of destroying the tissue chemically, such as with sterile ethanol acetic acid, or thermally by laser, microwave, or radiofrequency (1–3). Percutaneous ethanol injection therapy was the first method to be proposed (4). It was conceived independently at the University of Chiba in Japan and at the Vimercate Hospital in Milan, Italy.

Purpose To prospectively investigate the frequency and severity of postablation syndrome (PAS) and postprocedural pain in a cohort of patients undergoing hepatic microwave ablation. Materials and Methods From March 2009 to November 2011, 54 consecutive patients undergoing microwave ablation for liver tumors were enrolled. A questionnaire was administered to investigate PAS and pain at 1, 7, and 40 days after ablation. Four patients did not complete all three questionnaires and were excluded from the analysis. Additionally, laboratory tests with results known to significantly increase or decrease after ablation were performed, and ablation parameters were recorded. Potential predictors of PAS and pain at 1 and 7 days were evaluated by a logistic regression model. Results Fifty patients underwent a single microwave ablation session, 33 for hepatocellular carcinoma (HCC) and 17 for liver metastasis. Median ablation volumes on computed tomography were 31 cm 3 for HCC and 42 cm 3 for metastasis. Sixty percent of patients experienced PAS in the first week. Aspartate aminotransferase (AST) levels after ablation were significantly associated with PAS during postprocedure days 1–7. Median visual analog scale scores for pain at the puncture site were 1 and 0.24 at 1 and 7 days, respectively. The risk of having at least moderate pain in the first week was significantly related to ablation volume and time and postablation increase in AST level. Conclusions The incidence and severity of PAS with hepatic microwave ablation is similar to that reported for radiofrequency ablation, with the best predictive factor being postablation AST level elevation. Postablation pain was best predicted by total ablation volume and AST level.