The routine use of contrast enhanced ultrasound in the imaging work-up of focal liver lesions: A proposed algorithm

• Published in: Ultraschall in der Medizin - European Journal of Ultrasound
• Main Authors: Teoh, WC, Wong, KM, Wansaicheong, G
• Format: Conference Proceeding
• Language: English; German
• Published: 18.08.2016
• ISSN: 0172-4614; 1438-8782
• DOI: 10.1055/s-0036-1587844

Background: Grey scale ultrasound study of the liver is frequently performed for routine health screening or surveillance of high-risk patients. Our institution performs an average of 15000 ultrasound liver examinations a year. Focal liver lesions (FLL) are detected in about 10 – 15% of these patients, requiring further work up. Contrast enhanced ultrasound (CEUS) is now a widely accepted imaging technique for characterization of liver lesions. However, they are considered less established when compared to CT or MRI imaging. While various guidelines on its use in liver imaging have been published, some recommendations are not universally accepted or disputed by local and regional practices. We seek to establish a practical algorithm in which CEUS can be included as both a first line investigation or problem solving tool. Methods: We reviewed major guidelines available for surveillance of liver lesions and use of contrast-enhanced ultrasound. Appropriateness and cost effectiveness are major considerations when designing the algorithm. The proposed algorithm was discussed and endorsed by the institution's hepatobiliary multi-disciplinary team. Results: The proposed algorithm is based on two major considerations, patient's risk factors and size of detected FLL. Lesions smaller than 10 mm are generally observed rather than characterized. For low risk patients in which a benign aetiology is strongly expected, CEUS may be used as a first line investigation as there are strong evidences to suggest that CEUS is sensitive and has high predictive value for malignant lesions. For high-risk patients, CEUS is more commonly deployed as a problem-solving tool, when CT/MR evaluation is indeterminate or contraindicated. Conclusion: CEUS has been successfully integrated into our practice. It is deemed a reliable tool, particularly in the hands of experience operators. We hope our experience will help others introduce CEUS into their routine practice.