CEUS Non-Liver Guidelines - HD

Introduction

Thank you much Paul for the great pleasure with which I'm here and I thank you much for this kind invitation today.

I will talk firstly on non liver, have some guidelines and then I will approach CUS in thyroid and salivary glands.

Understanding the Need for Guidelines

Starting to understand why we need the guidelines. I used the sentence that Bernard was used to refer to try to give a meaning about experimental medicine that is nothing more than the reasoning by means of which the ideas undergone to the control of fats.

How can we do that? We may do experimental studies based on large population or by using evidence-based guidelines.

We know that there are a lot of application in which still CUS is considered off level means that we have to be conscious how to use when there is real indication which are the limitation.

I will not talk about liver guidelines because yesterday other colleagues already provided you the facts, the limitation and the indications.

Announcement of Guideline Updates

Let's move on Firstly to announce that we are going to renovate to update those guidelines in July. Paul CDO and all FSO members, the experts will be grouped together here in London and we are going to provide the update of these guidelines that were published in 2011, how those guidelines have been done and how we are going to do it.

Methodology for Developing Guidelines

Again, we know that these are based on a comprehensive literature survey in order to try to obtain evidence about indication limitation and possibility to use for far application.

Then we usually categorize by using level of evidence and at the end by using British guidelines for reporting.

We also provide the recommendation which are graded from a to zero depending on how strong is the evidence based on literature.

And again, these are also the way in which we classify papers.

Of course, all of us know that the systematic meta-analysis has higher value in order to provide evidence than personal expert opinion and then at the end we use also scale by which we can or not recommend that kind of use.

Technical Elements

First of all, some technical important elements. The dosage usually we nowadays recommend to use 2.4, however you can go down to one or increase to 4.8 especially when you are dealing with superficial organs.

General Considerations

Today I'm going to give you some general considerations. Then I will approach the indication, vascular pancreas, gastrointestinal tract, spleen, kidney ce, endoscopic ultrasound, atory reflux, abdominal trauma and then other small indications that are increasing every day as evidence.

Use in Pediatrics

Firstly, some comments about the use in P As already Paul stated this afternoon there will be a special session dedicated to it.

We know that by our personal experience CUS is effective also in pediatric population. However, still the second generation contrast agent is not yet approved so it is used as off level.

This means that we need to be very conscious and use it but by asking the permission to the health manager we can use it and there are evidence that it is very useful.

Safety Profile

What about safety? We may state that UCA are characterized by very high safety profile better than any other contrast agents used for C or MRI use.

Also we know that the rate of possible complications, especially the wars are very low.

However, we know also that there could be some important side effects and we recommend that resuscitation facilities should be available where in the place in which you are doing your examination of course we have to use as better as possible the proper dose in the proper clinical scenario.

This contrast agents, What about the possibility to use this contrast agents in patient with the renal failure?

There is evidence that in those patients, especially when there are contraindicated CT or M-R-I-C-U-S proved to be effective and safe.

Major Indications

Vascular Applications

But let's move on to the major indications. Firstly, vascular application, duplex ultrasound is nowadays considered the first imaging modality to evaluate a carotid stenosis.

However, sometimes we have some problems to differentiate especially occlusive from pre occlusive stenosis.

Then sometimes also we have some problems to delineate vascular borders and also to evaluate if a plaque is active or not.

According to the recommendation that were provided, there is level B one B in order to evaluate carotid neovascularization.

Then level B three when you have to differentiate total carotid occlusion from residual flow in tight stenosis and again the same recommendation also when you need to improve the lumen delineation in technically difficult carotid artery.

Let's see some example.

We tried to evaluate DYS stenosis but there was artifacts which limited our evaluation.

Then we inject contrast agent and you could see here how nicely you could eliminate border and you can make your measurements other tough case in which was not very easily depicted.

The stenosis it is occlusive or preclusive. Then we injected contrast agent Doesn't work. Okay, thank you.

And after the injection of contrast agent you can see how nicely you can delineate the border and you can discriminate an occlusive stenosis from a tight stenosis.

Then we may use contrast agent to evaluate neovascularization because it is very important in order to prevent ischemic events.

Color doper sound in these cases show that there is a tiny vessel within it but then we inject the contrast agent and you see the border are very nicely depicted but soon after microbubble enters in the plaque does showing that this is a neovascular plaque.

So very high risk plaque.

Again our experience together with the clever and other experts in order to evaluate end OICs which was proven especially with the new software to be very effective and in fact if you see the recommendation nowadays we have very strong evidence to recommend CS for the detection and characterization of end angelic in patient who have been treated for abdominal aorta and again also strong recommendation to follow up this kind of patient.

However, take in mind that the limitation are the same one as in baseline ultrasound depending on how much obese is the patient, how much IC and also if there is emphysema or diffusely calcification moving to the pancreas,

Pancreas

some very nice papers, famous papers that showed clearly that US may be useful to differentiate benign from malignant lesions and also to show very nicely and very precisely the typical features of a complex cystic mass to discriminate them and to also to show that there were very, there was very much concordance with the MRI and then pathology and in fact if you see characterization of data adenocarcinoma prove to have a recommendation as a one B.

Again another recommendation is to differentiate between cell disease and cystic tumors and to differentiate vascular from a vascular component of a lesion.

Gastrointestinal Tract

Again, other important application is the estimation of the activity of the small bowel disease and the highest recommendation this field is in that field to estimate that this is activity in inflammatory blood bowel disease is showing this case baseline ultrasound but then with CUS you could see how much an answered are these uh affected small bowel loops and again other case in which you could see how nicely and easily in real time you can depict the pathological small bowel and you can also do qualitative or quantitative evaluation by using software that are installed in your equipment or are external and provide you all the different parameters that nowadays we are using in the daily practice.

Spleen

What about spleen? The highest recommendation is to characterize splenic parenchyma in homogeneity or suspected lesion conventional ultrasound and in this field we reached the recommendation grade B one B but also to detect splenic al lesions in oncology patients.

Let's see this example. Tiny hyper coic lesion in a spleen, some vessel at power doppler.

Then we injected contrast agent and you could see here how nicely you can depict the vascularization of this lesion which maintained sustained hyper vascularity.

Also during the portal late phase and this was explaining hemangioma but you could also see how nicely you can depict and you can classify and also comparing with ct you may have resembling similar results in order to detect splenic infarcts.

Endoscopic Procedures

Moving to endoscopic procedure, COS may be used to discriminate high finance ductal adenocarcinoma of the pancreas from other ions to discriminate mass forming pancreatic lesion from chronic pancreatitis and also to improve the discrimination between cystic tumors from pancreatic cell tumors.

Kidney

What about kidney? The highest recommendation are to characterize as in this case this complex cystic renal lesion which was proven to be a malignant one and you could see here how nicely the scepter are thick and are announcing and again another important indication is also to evaluate and to follow up during and after procedures.

Patient who has renal cancer who have been treated with radiofrequency cryotherapy or microwave.

Very nice papers published by some friends from Italy show that you could use C US resembling similar results to ct but also you can discriminate, you can compare this image very nicely.

CAS reassemble CT in order to evaluate ischemic area.

What about the differentiation of different kidney lesions? Unfortunately in this field we have different experiences debating and especially showing sometimes contradictory results.

So to now at that time we were not able to provide any kind of recommendation and let's see the case of my experience in which we treated this patient with kidney tumor which was previously treated.

Again this is a relapse and then we did treat it and during the treatment after it we could see that the treatment was complete.

Scrotum

What about scrotum? There are some evidence that we may use CUS to discriminate hyper pronouncing from hyper pronouncing lesions to discriminate areas of viable tissue after trauma to detect and characterize segmental infection and to discriminate AB absence formation in severe pitis.

I show this case which was, which was done by our group and published also in a large series on radiology and we used both the possibility qualitative and quantitative evaluation in order to discriminate from other testicular lesions.

Abdominal Trauma

What about a trauma? I showed you already what we can do for spleen but we can apply CS in all the organs and we are using CUS as an alternative to CT in patient with minor trauma who are AMO amicably stable and also in order to reduce the number of thees of CT in patients that should be followed especially when they are very young and when they are stable.

I show this case liver trauma. We are following this very young guy who had a TRA a car trauma and then we depicted a pad laceration with hematoma and he's improving every month and we are, we reduce the three CT in these patients but what is important also is to use the right protocol.

We may examine patient with abdominal trauma by using only one bolus starting from the left, then coming to the right kidney, then evaluating liver and then spleen or we can use two bolus.

Lung and Pleural Lesions

What about the possibility to use USS in lung and pleural lesions? There is evidence classified as a recommendation B that could be useful to differentiate inflammatory from embolic lung consolidation but also in cases in which is not clearly differentiated abscess with pmo.

Again, we may use also to better evaluate brain vessel especially when colored doppler was inconclusive.

Lymph Nodes

And what about lymphoid at that time no much evidence was supporting the use for general use. The general use of COS for NOS evaluation but however Goldberg and other experts showed it that can be used but still is not clearly established.

And I will show you this case patient with melanoma, this inguinal lymph node with the thick thickened cortical aspect but then C US showed that it was an enhancing very homogeneously this was only a reactive lymph front.

Other Applications

Other possible application. What about blood transplanted kidney prostate at that time? Not much evidence but I anticipate to you that in the next guidelines we have nowadays more evidence that we can provide different recommendation but I don't want to announce something that is under preparation.

I would like just to show you some cases and especially this one we have to discriminate clot from urinary brother carcinoma and you could see here how nicely COS may help you to depict the vascularization and therefore to discriminate do lesion.

We use it also in this field software for quantification and we tried also to differentiate low from high grade carcinoma.

This is important because the treatment is different,

Conclusion

but in conclusion I hope to provide to have provided you different indication, clinical application limitation and especially that my talk would not confuse you even more.

And also I suggest you to attend the next euros, which will be held in IC and in which there will be also sessions dedicated to CUS.

And we will be also happy to provide you more information about pediatric Epsom statement paper that together with Pauli we are preparing and also the new guidelines.

And I thank you much for your kind attention.