v2017 CEUS v2017 update Yuko Kono, MD, PhD Clinical Professor of Medicine, Hepatology Clinical Professor of Radiology University of California, San Diego On behalf of CEUS Working Group October 5th, 2017 Bubble Conference Chicago
Federal grant support Disclosures 1 R01 CA 194307-01A1, 1 R01 CA215520-01A1 Industry grant/equipment/contrast material support Toshiba Medical Systems Co., GE Healthcare, Lantheus Medical Imaging Inc. Industry Speaker Bayer
CEUS WG members Yuko Kono Andrej Lyshchik Stephanie Wilson Tae Kim Hyun-Jung Jang MIT David Cosgrove Christoph Dietrich Fabio Piscaglia Juergen Willmann Claude Sirlin Alex Vezeridis New members Ex officio members Shuchi Rogers David Fetzer Hisham Tchelepi Avinash Kambadakone Cynthia Santillan Don Mitchell
HCC: Hepatocellular Carcinoma A worldwide healthcare problem 2nd cause of cancer death in the world Fastest growing cause of cancer death in the USA Risk factors Cirrhosis from any etiology (HBV, HCV, ETOH, NASH ) Chronic hepatitis B virus infection without cirrhosis Screening/surveillance US (+/- AFP) every 6 months To detect pre-clinical HCC at an early potentially curable stage Can be treated with surgical resection, liver transplantation or local ablation Diagnosis Majority of HCC is diagnosed by by imaging only without histology CECT/CEMRI are used for diagnosis CEUS is as accurate as CT/MRI, but not used widely AASLD, EASL, OPTN currently do not endorse use of CEUS for HCC diagnosis Background AASLD: American Association for the Study of Liver, Diseases, EASL: European Association for the Study of the Liver, OPTN: Organ Procurement and Transplantation Network
Background What is? Liver Imaging Reporting And Data System Standardized technique, terminology, interpretation, and reporting for liver imaging in patients at high risk for HCC Category codes reflecting relative probability for HCC Algorithm Untreated observation without pathologic proof in patient at high risk for HCC If cannot be categorized due to image degradation or omission If definite tumor in vein (TIV) If definitely benign If probably benign If probably or definitely malignant but not HCC specific (e.g., if targetoid) LR-NC LR-TIV LR-1 LR-2 LR-M Atlas Lexicon Comprehensive: full spectrum of lesions & pseudo-lesions, HCC with macro-vascular invasion, and non-hcc malignancies Otherwise, use CT/MRI diagnostic table below If intermediate probability of malignancy If probably HCC If definitely HCC CT/MRI Diagnostic Table Arterial phase hyperenhancement (APHE) Washout (not peripheral) Enhancing capsule Threshold growth No APHE APHE (not rim) Observation size (mm) < 20 20 < 10 10-19 20 LR-4 LR-5 Count major features: None LR-3 LR-3 LR-3 LR-3 LR-4 LR-3 LR-4 LR-5 One LR-3 LR-4 LR-4 LR-5 Two LR-4 LR-4 LR-4 LR-5 LR-5 Index
Organization Organization Steering Committee Sirlin support ACR Staff Approves new working groups and changes in working group leadership Guides Writing Group and approves Writing Group content Writing Group Sirlin Harmonizes activities and integrates output of working groups below Atlas & Lexicon Santillan harmonization RADLEX CT/MRI Technique Kambadakone Management Hecht & Fowler Pediatrics Towbin Reporting Chernyak International Tang Evidence McInnes Rx Response Do Benign Lesions Renot Rad Path Furlan Tech & Apps Kohli O & E Kielar & Elsayes Action Plan Bashir HBA Heiken & Fowler CEUS Kono US Kamaya harmonization harmonization harmonization provides members to O & E Working Group AASLD, OPTN, NCCN, etc. Pediatric & Pathology Societies RIS & PACS Vendors SAR HCC Disease Focus Panel
Members Contributors Updated on August 15, 2017
Diagnosis Category Codes CEUS LR-1 CEUS LR-2 CEUS LR-3 CEUS LR-4 CEUS LR-5 CEUS LR-TIV CEUS LR-M Definitely benign Probably benign Intermediate probability for HCC Probably HCC Definitely HCC Definite tumor in vein Malignant, not HCC specific
Diagnosis Category Codes CEUS LR-5 Definitely HCC
Untreated observation visible on pre-contrast US and without pathologic proof in patients at high risk for HCC Diagnosis If cannot be categorized due to image degradation or omission If tumor in vein (TIV) If definitely benign If probably but not definitely benign Probably or definitely malignant, not specific for HCC* Otherwise, use CEUS diagnostic table below If intermediate malignancy probability If probably HCC If definitely HCC CEUS Diagnostic Table CEUS LR-NC CEUS LR-TIV CEUS LR-1 CEUS LR-2 CEUS LR-M * CEUS LR-M criteria: Rim APHE OR Early (<60s) washout OR Marked washout CEUS LR-3 CEUS LR-4 CEUS LR-5 Arterial phase hyperenhancement (APHE) No APHE APHE ** Nodule size (mm) < 20 20 < 10 10 No washout of any type CEUS LR-3 CEUS LR-3 CEUS LR-3 CEUS LR-4 Late and mild washout CEUS LR-3 CEUS LR-4 CEUS LR-4 CEUS LR-5 ** APHE: Not rim (indicates LR-M) Not peripheral discontinuous globular (indicates hemangioma)
LR-5 Definite HCC VS LR-M Malignant, not HCC Specific Major Features AND CEUS LR-5 APHE in whole APHE in part 2.5 min Late (> 60s) & Mild Washout OR CEUS LR-M AP Rim Enhancement 1min Marked OR Early Washout
CEUS 5: Definitely HCC Cases 63 yo female with alcohol cirrhosis 2 min 2min AP Arterial phase hyperenhancement (APHE) No APHE 3 min3min 5 min 5min APHE Observation size (mm) < 20 20 < 10 10 No washout of any type CEUS LR-3 CEUS LR-3 CEUS LR-3 CEUS LR-4 Late and mild washout CEUS LR-3 CEUS LR-4 CEUS LR-4 CEUS LR-5
Current Studies & Future Directions CEUS v2017 core/essential deck was released in September 2017 Currently working on CEUS v2017 manual Future work Treatment response Sonazoid Validation studies Retrospective studies: Canadian study (Dr. Wilson) Italian study (Dr. Piscaglia) Prospective multicenter trial (R01 NIH grant Dr. Lyschick) Initiation expected in a few week Future
Future CEUS Prospective Trial Institution Alberta Health Services, Calgary, Canada Einstein Medical Center, Philadelphia, PA King's College Hospital, London, United Kingdom Stanford Medical Center, Stanford, CA Swedish Medical Center, Seattle, WA Thomas Jefferson University Hospital, Philadelphia, PA University of Bologna, Bologna, Italy University of California, San Diego, CA Principal Investigator Stephanie Wilson, M.D. Mindy Horrow, M.D. Paul Sidhu, M.D. Aya Kamaya, M.D. Lisa Finch, M.D. Andrej Lyshchik, M.D., Ph.D. Fabio Piscaglia, M.D. Yuko Kono, M.D. Vanderbilt University Medical Center, Nashville, TN Participating Institutions Geoffrey Wile, M.D.
Future Future One System Validation & adoption
CEUS resource Resource ACR website https://www.acr.org/qualitysafety/resources/lir ADS Downloadable v2017 CEUS core and essential slides v2017 CEUS manual will be available soon EFSUMB webinar 1/19/2017 on CEUS http://www.efsumb.org/education/ed-webinararchive.asp