Guidelines for Use of Contrast-Enhanced Ultrasonography (CEUS) in the Liver (WFUMB, 2020)

World Federation for Ultrasound in Medicine and Biology (WFUMB)

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

November 03, 2020

The guidelines on the use of contrast-enhanced ultrasonography (CEUS) in the liver were published in October 2020 by the World Federation for Ultrasound in Medicine and Biology (WFUMB).[1]

Indications, Contraindications, and Safety Considerations

Intravenous (IV) use of ultrasound contrast agents (UCAs) in adult populations is safe. Intravenous use of UCAs in pediatric populations is safe.

Intracavitary use of UCAs is safe. 

Differences Between CEUS and Other Contrast-Enhanced Imaging Modalities

CEUS is recommended in patients with inconclusive findings at computed tomography (CT) or magnetic resonance imaging (MRI).

CEUS should be considered as the first contrast imaging modality in patients with renal insufficiency.

Detection of Malignant Focal Liver Lesions

CEUS can be used for liver metastasis detection as part of a multimodality imaging approach.

Routine use of CEUS for surveillance of patients at risk for hepatocellular carcinoma (HCC) is not recommended.

Routine use of CEUS for staging of HCC is not recommended.

Characterization of Focal Liver Lesions

Before CEUS is performed to characterize focal liver lesions (FLLs), it is recommended that a systematic liver examination be performed using B-mode and Doppler ultrasonography (US).

CEUS is recommended as the first-line imaging technique for characterizing incidentally detected, indeterminate FLLs at US in patients with noncirrhotic livers and no history or clinical suspicion of malignancy.

CEUS is suggested as the first-line imaging technique for the characterization of FLLs detected with US in patients with a noncirrhotic liver with a history or clinical suspicion of malignant disease.

CEUS is recommended for the characterization of FLLs in the noncirrhotic liver in patients with inconclusive findings at CT or MRI and is suggested if biopsy of the FLL was inconclusive.

CEUS is recommended for characterizing FLLs in noncirrhotic livers if both CT and MRI are contraindicated.

If CEUS has definitively characterized a benign FLL, further investigations to confirm the diagnosis are not recommended.

CEUS can be used to characterize hepatic abscess in the appropriate clinical setting.

Characterization of Focal Liver Lesions in Liver Cirrhosis

CEUS can be utilized as the first line for characterizing FLLs found in patients with liver cirrhosis to establish a diagnosis of malignancy (CEUS LR-M)—or, specifically, HCC (CEUS LR-5)—but CT or MRI is required for accurate staging unless contraindicated.

CEUS can be utilized when CT or MRI is inconclusive, especially in FLLs in cirrhotic livers not suitable for biopsy, to assess the probability that a lesion is an HCC.

CEUS can be utilized for the selection of FLL(s) in a cirrhotic liver to be biopsied when they are multiple or have different contrast patterns.

CEUS can be used to monitor changes in enhancement patterns in FLLs in cirrhotic livers requiring follow-up.

Characterization of Portal Vein Thrombosis

CEUS is recommended for differentiation between benign and malignant portal vein thrombosis.

Contrast-Enhanced Intraoperative Ultrasonography

Contrast-enhanced intraoperative US (CE-IOUS) can be used to detect and characterize FLLs not detected at preoperative imaging.

CE-IOUS is recommended for assessment of the region for resection, where a pretreatment colorectal liver metastasis was present but has regressed.

Guidance of Biopsy

CEUS guidance should be attempted for biopsy of FLLs that are invisible or inconspicuous at B-mode imaging.

CEUS guidance should be considered for FLLs with potential necrotic areas or if previous biopsy resulted in necrotic material.

Intracavitary Uses

Intracavitary CEUS (ICCEUS) can be used to delineate the liver abscess cavity and identify correct drain position and communication with other structures.

ICCEUS can be used to guide transhepatic biliary interventions.

Interventional Tumor Ablation

CEUS before a US-guided ablation procedure is recommended as a complement to US, CT, and MRI for treatment planning.

CEUS guidance is recommended for US-guided ablation of tumors that are invisible or inconspicuous on US.

CEUS is recommended for evaluation of the treatment effect after ablation and guidance of immediate US-guided retreatment of residual tumor.

CEUS is recommended as the priority imaging method in follow-up after ablation to identify residual/recurrent tumor at appropriate intervals.

Monitoring of Medical Treatment Response

Dynamic CEUS (DCEUS) can be used in the quantitative assessment of response to targeted therapies in patients with malignant tumors of the liver.

CEUS assessment of FLLs in children is consistent with findings in adult patients, and it should be used to characterize these lesions.

CEUS follow-up of traumatic liver injuries in children should be utilized for assessment of complications, reducing ionizing radiation exposure.

For more information, please go to Hepatocellular Carcinoma Imaging, Portal Vein Thrombosis Imaging, and Cirrhosis Imaging.

For more Clinical Practice Guidelines, please go to Guidelines.


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