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US-guided percutaneous biopsy of focal liver lesions (FLL) is a classic interventional procedure performed by almost all radiology units. Typically, an incidental focal finding on US or a focal indeterminate lesion diagnosed on CT, MRI or PET/CT is referred for US-guided biopsy for final diagnosis. The introduction of microbubble US contrast agents has overcome some of the limitations of standard US in diagnosing FLLs by displaying the microvasculature together with the US morphology, which has increased both the sensitivity and the specificity. The combination of CEUS and intervention is facilitated by newer US equipment providing split-screen mode, which displays the CEUS mode alongside the standard US mode simultaneously on a single monitor. The puncture line is displayed in both modes as well as on the monitor. The interventional device (i. e., biopsy needle) is typically best visualized in the standard US mode, while the characteristic tissue pattern in an FLL is typically best visualized in CEUS mode. There are 3 main categories in which CEUS has an impact on US-guided biopsy of FLLs: • CEUS improves the visualization of FLLs • CEUS improves the quality of the biopsy specimen from an FLL • CEUS reduces the need for US-guided biopsy of an FLL In the two first categories, CEUS is utilized simultaneously with US-guided biopsy to ensure correct needle targeting. In the last category, US-guided biopsy of the FLL becomes superfluous as a result of the CEUS examination.

This article represents part 3 of the EFSUMB Recommendations and Guidelines for Gastrointestinal Ultrasound (GIUS). It provides an overview of the examination techniques recommended by experts in the field of endorectal/endoanal ultrasound (ERUS/EAUS), as well as perineal ultrasound (PNUS). The most important indications are rectal tumors and inflammatory diseases like fistula and abscesses in patients with or without inflammatory bowel disease (IBD). PNUS sometimes is more flexible and convenient compared to ERUS. However, the technique of ERUS is quite well established, especially for the staging of rectal cancer. EAUS also gained ground in the evaluation of perianal diseases like fistulas, abscesses and incontinence. For the staging of perirectal tumors, the use of PNUS in addition to conventional ERUS could be recommended. For the staging of anal carcinomas, PNUS can be a good option because of the higher resolution. Both ERUS and PNUS are considered excellent guidance methods for invasive interventions, such as the drainage of fluids or targeted biopsy of tissue lesions. For abscess detection and evaluation, contrast-enhanced ultrasound (CEUS) also helps in therapy planning.

In pediatrics ultrasound has long been viewed more favorably than imaging that exposes patients to radiation and iodinated contrast or requires sedation. It is child-friendly and diagnostic capabilities have been improved with the advent of contrast-enhanced ultrasound (CEUS). The application of CEUS is indeed promising. However, no ultrasound contrast agent manufactured today is registered for pediatric use in Europe. The contrast agent SonoVue® has recently been approved by the FDA under the name of Lumason® to be used in hepatic investigations in adults and children. This article reviews the literature with respect to 2 specific applications of CEUS in children: 1) identification of parenchymal injuries following blunt abdominal trauma, and 2) classification of focal liver lesions. Applications were chosen through the CEUS guidelines published by the European Federation of Societies for Ultrasound in Medicine and Biology and World Federation for Ultrasound in Medicine and Biology. Literature was obtained by searching Medline and Pubmed Central (using Pubmed), Scopus database and Embase. CEUS proved to be an effective investigation in the hemodynamically stable child for identifying parenchymal injuries and for the characterization of focal liver lesions. CEUS showed comparable performance to CT and MRI with a specificity of 98% for identifying benign lesions and a negative predictive value of 100%. For the applications reviewed here, CEUS holds promising perspectives and can help reduce radiation exposure and use of iodinated contrast agents in pediatrics, thereby potentially reducing complications in routine imaging.

Purpose Ablation is a valuable treatment alternative to surgery for colorectal liver metastases. This study reports the long-term clinical outcomes in patients treated with ablation for colorectal liver metastases with or without extrahepatic metastases. Methods Patients with colorectal liver metastases treated with ultrasound-guided ablation at Herlev Hospital, Denmark were included in this retrospective study. Results This study included 284 patients with 582 metastases. Complete ablation was obtained in 258 patients (91%) evaluated within 6 weeks. During follow-up, 94 patients (33%) developed local recurrence. The median survival for all patients was 31 months, with 1-, 3-, and 5-year survival rates of 82%, 45%, and 21%, respectively. The median survival for patients with extrahepatic metastases (n=49, 17%) was 24 months compared with 33 months for patients without (P=0.142). Propensity score-adjusted Cox regression showed that extrahepatic metastases were associated with increased mortality, with a hazard ratio (HR) of 1.45 (95% confidence interval [CI], 1.02 to 2.05; P=0.039). In multivariate Cox regression analysis for all patients, increased mortality risk was found for a diameter ≥2.6 cm (HR, 1.59; 95% CI, 1.23 to 2.05), >1 metastasis (HR, 1.66; 95% CI, 1.28 to 2.16), and extrahepatic metastases (HR, 1.45; 95% CI, 1.04 to 2.03). Male sex (HR, 0.75; 95% CI, 0.58 to 0.98) and receiving chemotherapy (HR, 0.69; 95% CI, 0.52 to 0.92) were associated with decreased mortality. Conclusion Ablation for colorectal liver metastases offers acceptable survival rates, including for patients with extrahepatic metastases. In addition, chemotherapy was associated with improved survival for both patients with and without extrahepatic metastases.

Purpose: This research aims to understand key problems and identify possible solutions in the market for radiology equipment in low- and middle-income countries. Methods and Materials: This paper uses simple descriptive statistics to summarize the results of responses from 574 radiologists from 52 countries surveyed in April-May 2017, and 15 hardware and software vendors from six countries surveyed in September-October 2017. Results: Radiologists surveyed came from both public and private sectors and were drawn from Radiological Society of North America (RSNA) members who, according to the survey results, appear to represent sites with more advanced technology. Virtually all the radiologists worked at sites where both X-ray and ultrasound were available, and the overwhelming majority (93%) had access to CT. Digital technology has gone worldwide: radiologists in all countries reported that digital radiography was either equally or more available than analog technologies. Sixty percent of radiologists said that they were “always” or “often” involved in the purchasing decisions in their institutions, but only 35% reported that they had the final say. According to the radiologists surveyed, the era of donated equipment is ending. Ninety-five percent felt that the disadvantages of donated equipment outweighed the cost savings. Training was a key concern both for radiologists and vendors. Radiologists felt that training was insufficient, materials left behind too complicated, online materials too limited, and follow-up from vendors insufficient. Vendors pointed out that the bidding process often excluded the cost of training and support and that many purchases are made through local distributors and they lack direct contact with vendors. Conclusion: While digital radiology is spreading throughout the surveyed countries, access to advanced imaging remains limited. Donated equipment is no longer a major solution to limited equipment availability. There is an opportunity for vendors and radiologists to work together to ensure that training, service and support are always included in purchases.

The intent of this review is to discuss and comment on common clinical scenarios in which contrast-enhanced ultrasonography (CEUS) may play a decisive role and to illustrate important points with typical cases. With the advent of CEUS, the scope of indications for ultrasonography has been dramatically extended, and now includes functional imaging and tissue characterization, which in many cases enable tumor diagnosis without a biopsy. It is virtually impossible to imagine the practice of modern medicine as we know it in high-income countries without the use of imaging, and yet, an estimated two thirds of the global population may receive no such care. Ultrasound imaging with CEUS has the potential to correct this inequity.