Contrast-enhanced ultrasound for liver imaging: recent advances

Contrast-enhanced ultrasonography (CEUS), providing relevant informations not available with non-enhanced ultrasonography, greatly impacted the practice of liver imaging. The characterization of focal liver lesions (FLLs), is obtained in a rapid, accurate and safe way and is considered the main hepatic indication; however CEUS offers other established or emergent relevant applications. Metastases detection and assessment of response to locoregional tumor treatment are accepted applications with specific indications. Needle guidance in case of poorly or non visible target lesions at conventional ultrasound is also accepted. The early assessment of response to systemic treatment, and in particular to antiangiogenic ones, by quantification software is an emergent application. The manageability of CEUS determined also its use in the operating theatre, improving the accuracy of intraoperatory US with a significant impact on final surgical strategy. In cirrhotic patients, the role of CEUS was proven highly accurate and sensitive in the characterization of portal vein thrombosis, by identification of contrast arterial enhancement inside the thrombus, that occurs only in case of neoplastic origin. In recent years microbubbles taken up by Kupffer cells, thus possessing a "postvascular" phase, were registered as ultrasound contrast agent in Japan (Sonazoid). During the post-vascular phase tumoral tissue tend to appear as a contrast defect image due to the lack of Kupffer cells, strongly contributing to tumor staging beside characterization. Newly developed techniques, such as fusion imaging or real-time three dimensional US, in addition to other applications of CEUS, in terms of post-transplantation or cholecystitis-related complications, have been recently proposed and will be discussed.