The Role of US Contrast Agents in US-Guided Biopsy of Focal Liver Lesions: A Pictorial Review

Abstract

US-guided percutaneous biopsy of focal liver lesions (FLL) is a classic interventional procedure performed by almost all radiology units. Typically, an incidental focal finding on US or a focal indeterminate lesion diagnosed on CT, MRI or PET/CT is referred for US-guided biopsy for final diagnosis. The introduction of microbubble US contrast agents has overcome some of the limitations of standard US in diagnosing FLLs by displaying the microvasculature together with the US morphology, which has increased both the sensitivity and the specificity. The combination of CEUS and intervention is facilitated by newer US equipment providing split-screen mode, which displays the CEUS mode alongside the standard US mode simultaneously on a single monitor. The puncture line is displayed in both modes as well as on the monitor. The interventional device (i. e., biopsy needle) is typically best visualized in the standard US mode, while the characteristic tissue pattern in an FLL is typically best visualized in CEUS mode. There are 3 main categories in which CEUS has an impact on US-guided biopsy of FLLs: • CEUS improves the visualization of FLLs • CEUS improves the quality of the biopsy specimen from an FLL • CEUS reduces the need for US-guided biopsy of an FLL In the two first categories, CEUS is utilized simultaneously with US-guided biopsy to ensure correct needle targeting. In the last category, US-guided biopsy of the FLL becomes superfluous as a result of the CEUS examination.

Key words

contrast agents - ultrasound - biopsy - tumor

• References

• 1 Lorentzen T, Nolsøe C. Interventional ultrasound – general principles and applications in gastroenterology ASUM. Ultrasound Bulletin 2008; 11: 25-29
• 2 Lorentzen T, Nolsøe CP, Ewertsen C. et al. EFSUMB guidelines on interventional ultrasound (INVUS), part I: General aspects (long version). Ultraschall Med 2015; 36: E1-E14
• 3 Ghent CN. Percutaneous liver biopsy: Reflections and refinements. Can J Gastroenterol 2006; 20: 75-79
• 4 Skjoldbye B, Bachmann Nielsen M, Nolsøe C. Ultrasound contrast agents in diagnosis of focal liver lesions. ASUM Ultrasound Bulletin 2007; 10: 32-34
• 5 Strobel D, Seitz K, Blank W. et al. Contrast-enhanced ultrasound for the characterization of focal liver lesions–diagnostic accuracy in clinical practice (DEGUM multicenter trial). Ultraschall Med. 2008; 29: 499-450
• 6 Larsen LP, Rosenkilde M, Christensen H. et al. The value of contrast enhanced ultrasonography in detection of liver metastases from colorectal cancer: A prospective double-blinded study. Eur J Radiol 2007; 62: 302-307
• 7 Piscaglia F, Bolondi L. The safety of SonoVue in abdominal applications: Retrospective analysis of 23,188 investigations. Ultrasound Med Biol 2006; 32: 1369-1375
• 8 Nolsøe CP, Nolsøe AB, Klubien J. et al. Use of ultrasound contrast agents in relation to percutaneous interventional procedures: A systematic review and pictorial essay. J Ultrasound Med 2018; 37: 1305-1324
• 9 Francica G, Meloni MF, de Sio I. et al. Biopsy of Liver Target Lesions under Contrast-Enhanced Ultrasound Guidance - A Multi-Center Study. Ultraschall Med. 2017; DOI: 10.1055/s-0043-122496.
• 10 Schlottmann K, Klebl F, Zorger N. et al. Contrast-enhanced ultrasound allows for interventions of hepatic lesions which are invisible on conventional B-mode. Z Gastroenterol 2004; 42: 303-310
• 11 Partovi S, Lu Z, Kessner R. et al. Contrast enhanced ultrasound guided biopsies of liver lesions not visualized on standard B-mode ultrasound-preliminary experience. J Gastrointest Oncol 2017; 8: 1056-1064
• 12 Yoon SH, Lee KH, Kim SY. et al. Real-time contrast-enhanced ultrasound-guided biopsy of focal hepatic lesions not localised on B-mode ultrasound. Eur Radiol 2010; 20: 2047-2056
• 13 Park HS, Kim YJ, Yu MH. et al. Real-time contrastenhanced sonographically guided biopsy or radiofrequency ablation of focal liver lesions using perflurobutane microbubbles (Sonazoid):Value of Kupffer-phase imaging. J Ultrasound Med 2015; 34: 411-421
• 14 Spârchez Z, Radu P, Kacso G. et al. Prospective comparison between real time contrast enhanced and conventional ultrasound guidance in percutaneous biopsies of liver tumors. Med Ultrason 2015; 17: 456-463
• 15 Park HJ, Lee MW, Lee MH. et al. Fusion imaging-guided percutaneous biopsy of focal hepatic lesions with poor conspicuity on conventional sonography. J Ultrasound Med 2013; 32: 1557-1564
• 16 Conti CB, Cavalcoli Fl, Fraquelli Ml. et al. Ultrasound elastographic techniques in focal liver lesions. World J Gastroenterol 2016; 22: 2647-2656
• 17 Wu W, Chen MH, Yin SS. et al. The role of contrast-enhanced sonography of focal liver lesions before percutaneous biopsy. AJR Am J Roentgenol 2006; 187: 752-761
• 18 Eso Y, Takai A, Takeda H. et al. Sonazoid-enhanced ultrasonography guidance improves the quality of pathological diagnosis in the biopsy of focal hepatic lesions. Eur J Gastroenterol Hepatol 2016; 28: 1462-1467
• 19 De Marchi A, Brach del Prever EM, Linari A. et al. Accuracy of coreneedle biopsy after contrast-enhanced ultrasound in soft-tissue tumours. Eur Radiol 2010; 20: 2740-2748
• 20 Mao F, Dong Y, Ji Z. et al. Contrast-enhanced ultrasound guided biopsy of undetermined abdominal lesions: A multidisciplinary decision-making approach. Biomed Res Int 2017; 2017: 8791259
• 21 Sparchez Z, Radu P, Kacso G. et al. Contrastenhanced ultrasound guided biopsy of superficial thoraco-abdominal and neck lesions: Initial experience in 20 patients. Med Ultrason 2012; 14: 288-293
• 22 Claudon M, Dietrich CF, Choi BI. et al. Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS) in the liver—update 2012: A WFUMB-EFSUMB initiative in cooperation with representatives of AFSUMB, AIUM, ASUM, FLAUS and ICUS. Ultrasound Med Biol 2013; 39: 187-210
• 23 Friedrich-Rust M, Klopffleisch T, Nierhoff J. et al. Contrast-enhanced ultrasound for the differentiation of benign and malignant focal liver lesions: A meta-analysis. Liver Int 2013; 33: 739-755
• 24 Guang Y, Xie L, Ding H, Cai A, Huang Y. Diagnosis value of focal liver lesions with SonoVueVR -enhanced ultrasound compared with contrast-enhanced computed tomography and contrastenhanced MRI: A meta-analysis. J Cancer Res Clin Oncol 2011; 137: 1595-1605
• 25 Westwood M, Joore M, Grutters J. et al. Contrast-enhanced ultrasound using SonoVueVR (sulphur hexafluoride microbubbles) compared with contrast-enhanced computed tomography and contrastenhanced magnetic resonance imaging for the characterisation of focal liver lesions and detection of liver metastases: A systematic review and cost-effectiveness analysis. Health Technol Assess 2013; 17: 1-243
• 26 Xie L, Guang Y, Ding H, Cai A, Huang Y. Diagnostic value of contrast-enhanced ultrasound, computed tomography and magnetic resonance imaging for focal liver lesions: A meta-analysis. Ultrasound Med Biol 2011; 37: 854-861
• 27 Nolsøe C, Lorentzen T. International guidelines for contrast-enhanced ultrasonography: Ultrasound imaging in the new millennium. Ultrasonography 2016; 35: 89-103
• 28 Sidhu PS, Brabrand K, Cantisani V. et al. EFSUMB guidelines on interventional ultrasound (invus), part ii. diagnostic ultrasound-guided interventional procedures (long version). Ultraschall Med. 2015; 36: E15-E35
• 29 Dietrich CF, Mertens JC, Braden B. et al. Contrast-enhanced ultrasound of histologically proven liver hemangiomas. Hepatology 2007; 45: 1139-1145
• 30 Dietrich CF, Schuessler G, Trojan J. et al. Differentiation of focal nodular hyperplasia and hepatocellular adenoma by contrast-enhanced ultrasound. Br J Radiol 2005; 78: 704-707
• 31 Hirche TO, Ignee A, Hirche H. et al. Evaluation of hepatic steatosis by ultrasound in patients with chronic hepatitis C virus infection. Liver Int 2007; 27: 748-757
• 32 Joo I, Choi BI. New paradigm for management of hepatocellular carcinoma by imaging. Liver Cancer 2012; 1: 94-109
• 33 Bohle Wl, Clemens PU, Heubach T, Zoller WG. Contrast-enhanced ultrasound (CEUS) for differentiating between hepatocellular and cholangiocellular carcinoma. Ultraschall Med. 2012; 33: E191-E195
• 34 Chen I, Lorentzen T, Linnemann D. et al. Seeding after ultrasound-guided percutaneous biopsy of liver metastases in patients with colorectal or breast cancer. Acta Oncol. 2016; 55: 638-643