The EFSUMB and WFUMB Guidelines and Recommendations on the Clinical Practice of Contrast Enhanced Ultrasound (CEUS).
Update 2011 on Hepatic (EFSUMB and WFUMB) and Non-hepatic Applications (EFSUMB)

 

Contrast-enhanced ultrasound (CEUS) was originally introduced to enhance Doppler signals of macrovessels. With the introduction of sulphur hexafluoride (SonoVue ®), real time low mechanical index (MI) contrast-enhanced ultrasound was introduced to analyse the microvascularity. Because of their physical size (at or smaller than red blood cells), ultrasound contrast agents (UCAs) act as pure blood pool agents which explains some of the advantages of CEUS.

The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) introduced the first Guidelines on the use of CEUS in 2004. This document mainly focused on liver applications. New applications, in addition to the liver, were developed in the following years. Therefore, in the update of the clinical recommendations on the use of CEUS by the EFSUMB, published in 2008, applications to other organs were described as well. In the following years an increasing interest in the clinical applications of CEUS technique and new fields has been investigated, so that up to now nearly all organ systems have been subject to CEUS studies. Therefore, in 2010 EFSUMB initiated a new update of guidelines.

Also regarding future perspectives of CEUS, it was felt that a new update on CEUS liver applications should be prepared and published on a worldwide basis since liver indications are the most common used applications so far. Therefore, an agreement was concluded with the World Federation of Societies for Ultrasound in Medicine and Biology (WFUMB) to prepare joint guidelines exclusively on liver applications, taking advantage of the experience of EFSUMB and of the previously published documents. This new article will be issued as a simultaneous publication in Ultraschall in der Medizin/European Journal of Ultrasound and in Ultrasound in Medicine and Biology also to reflect the world wide use of CEUS and the effective collaboration of the societies.

The content include general considerations (technical aspects), characterization of focal liver lesions (FLL) in the non cirrhotic liver, characterization of FLL in the cirrhotic liver, characterization of portal vein thrombosis and biopsy related description. Detection of FLL with the transabdominal approach, intraoperative CEUS, monitoring ablative treatment, liver transplantation, contrast quantification and monitoring of systemic treatment, safety aspects and technical appendices.

At the same time EFSUMB decided to explore the published literature for evidence of established but also of additional indications. Reports on numerous offlabel extravascular or intracavitary administration of SonoVue have been also published in recent years. In the tradition of earlier EFSUMB recommendations these clinical recommendations on the use of CEUS are based on comprehensive literature surveys particularly including results from prospective clinical trials. They are intended to create standard protocols for the use and administration of UCA and improve the management of patients. Recommendations are based on the literature and the experts’ consensus to provide a categorization of the level of evidence and a level (strength) of recommendation for each indication. Thematic sections of the manuscript include description of equipment, investigators’ training, terminology, safety aspects, pediatric indications, pancreas including endoscopic contrast-enhanced ultrasound, extrahepatic biliary system, gastrointestinal tract and perineum, spleen, kidney, use of CEUS in patients with renal failure, transplanted kidney, adrenals, urinary bladder, vesi-coureteral reflux, prostate, scrotum, abdominal trauma, lung and pleural lesions, vascular applications including aorto-caval fistulae and cerebral vessels, rheumatology (inflammatory joint disease), extravascular (intracavitary) applications, analysis of lymph nodes, tumor response assessment and free tissue transplants. Breast and other gynecological indications are included in the manuscript as well. Some of the indications are established whereas others are not which are categorized as emergent CEUS applications since evidence is insufficient for general recommendation. The manuscript also discusses safety aspects and includes a technical appendix and selected references.

Reference: F. Piscaglia, C. Nolsøe, C. F. Dietrich, D. O. Cosgrove, O. H. Gilja, M. Bachmann Nielsen, T. Albrecht, L. Barozzi, M. Bertolotto, O. Catalano, M. Claudon, D. A. Clevert, J. M. Correas, M. D’Onofrio, F. M. Drudi, J. Eyding, M. Giovannini, M. Hocke, A. Ignee, E. M. Jung, A. S. Klauser, N. Lassau, E. Leen, G. Mathis, A. Saftoiu, G. Seidel, P. S. Sidhu, G. ter. Haar, D. Timmerman, H. P.Weskott. The EFSUMB Guidelines and Recommendations on the Clinical Practice of Contrast Enhanced Ultrasound (CEUS): Update 2011 on non-hepatic applications. Ultraschall Med 2011