Taking CEUS to New Depths

Hello everyone, my name is Anders Nilsson. I work at the Lund University Hospital in southern Sweden and first of all I'd like to thank Semans to giving me the opportunity to share some thoughts with you about how ultrasound can be used. First of all I have to take you back a little bit in history and tell you how we ended up really where we are now with with trans, not just what we're eating but with. Transduces that we have. So this I'm not going to say that actually worked with this machinery. If I did, I wouldn't admit it. But this is a single crystal static scanner ultrasound where you just pull the single single crystal transducer over the patient and then someone we're in the 70s now and then someone came up with a brilliant idea of placing that single crystal on a wheel so it could rotate. And then we get certain live images, real time images and then that was the image quality was a bit dubious, so we went to this where someone came up with the idea of instead of having one crystal rotates, let put. Let's put plenty of crystals in a row and then fire them one at a time and then we ended up with transducers like this which is a 3.5 megahertz linear transducer for the acuson 128 in. Sort of late late 80s. This one has a footprint of about 12 centimeters, which makes it in theory fantastic. It's a linear transducer. It'll give you a fantastic image quality if you can get an image, but in ultrasound, as you know, we talk about working with Windows into the abdomen and this one has a 12 centimeter footprint and I've been doing ultrasound for 30 plus years. I have still haven't found a window that is 12 centimeters anywhere in. In the abdomen, if either of you have found it, please email me and tell me where it is so these transducers were basically impossible to use. And then of course we came up with with these ideas where you have curved array transducer where you have a smaller footprint so you can use a decent window, slightly fan shaped to give you an idea of where you are, and then you have. If you have a smaller footprint you have the vector transducers and because they were needed in the abdomen we tend to have them with with a low frequency right the linear transducers. They they used for small parts like thyroids and things like that and superficial things because then you don't need the fan shaped image to know where you are and what you're actually looking at. But because we use it for small parts we tend to have high megahertz on the linear transducers and low megahertz on the curved array and vector transducers. Now they're as they say, in America there is no such thing as a free lunch, and that is actually true. So the situation we have is if you have a high frequency transducer, you have a good spatial resolution. If you have a low frequency, then you have a good penetration. But now we're getting to the points that I'd like to make. Is that if we can have better modern transducers, better transducer technology. You get something. You can use the improvement to either go deeper with the standard curved array transducer and still have a decent image quality, or you can you can use a linear transducer with this superior spatial resolution that a linear transducer will have and actually go into the parameters organs of the abdomen. This is one example of the first thing that I mentioned. You have a lesion on pet. You can see it on on the pet image as high signal in in the dorsal part of the liver. You can actually see it on the CT as well as arterial enhancing and the patient as you can see is is that Arctic and and it's with with the standard curved array abdominal transducer even with. With the fusion to guide us to the right area, we can't quite see it, and the query here is that, can you ablate it and find we can debate it with microwaves by going with the fusion image? But it's also it's so much nicer to actually see what you're shooting at. So this is still the standard abdominal transducer, but if we go to something that is designed to actually penetrate. You can see here you can actually see the lesion now, which is fantastic because then we can actually ablate it and you see you have you see the lesion and we have a uniform echogenicity. We've lost spatial resolution, but you have a uniform echogenicity throughout the image. Now, here's here's the standard situation. We know this is cirrhotic patient. We have detected a lesion with a curved array transducer. We have arterial phase hyper enhancement. And. Sort of put Venus face still hyper enhancing, but in extended late phase we have. A bit of a washout, so this would be a series liar. Adds five. It would definitely be an HCC very suspicious of, but. Now you might say this is good enough and the concept of good enough crops up from time to time and good enough is never good enough, because if you think about it, the lesion that you didn't see, you don't know that you missed it. So what we need to do is to strive for the best image quality with a combination of hardware and software that is possible. So this is the same lesion that you saw with the curved array transducer before, but on this one where we where we were able to use linear transducers in the abdomen, you can see not only that it's a focal lesion, but you can see the lesion in lesion and in the right image you can actually see the contrast enhancement in the arterial phase being in that lesion in lesion so. We've we've in this patient. It doesn't make C really make a difference, but in another patient in might and you can see that this is this is a more detailed image. Another situation where we have a patient with with a history of malignancy and we have focal lesions that we can see in the liver. We can see them on the contrast enhanced image. We can suspect them on the B mode image, but we're talking about lesions and size of four or five millimeters and no surgeon is going to do surgery on that. No oncologist is going to do chemo if this is all you see, so we need a biopsy. And then. Actually hitting a 4 millimeter lesion with a curved array transducer in a contrast enhanced image because we can't see them on the B mode is tricky in the least, but if we can use a linear transducer, we can actually go to the place where we know there was a lesion. And as you can see, the lesion is visible at measuring 5 millimeters. In this particular case, and we can do a biopsy. So as you remember, if we're going to shoot, that's something we need to see it. If we can't see it, we can't hit it. So this is an example. You have a small Hemangioma in the middle there. This is a linear transducer penetrating 9 centimeters into the abdomen, and if you look carefully, next time it goes through, there's a little cyst in the near field. Somewhere up here will a little cyst will appear there, and you can actually see it. You can't see that on a curved array transducer because you have have the reverberation artifacts up there. But with with if we can go with a linear transducer, same same patient, you can see that we're down to 10 centimeters in a standard patient. We can use a linear transducer and look through the entire right lobe of the liver, not just the left. And with that sort of that, penetration goes for contrast as well. I think this is the patient where I've been the most certain of an FNH diagnosis. You can see the literally every little bubble of contrast. Not really, but feels like that coming from the center of the lesion and going out. Now here's another patient where. Better transducer technology where you have a better penetration both with with B mode image and contrast really helps. This is an incidental. Finding this patient with no history of liver disease and it's the scan is done to to rule out gallstones and I think most of us would say that in a completely healthy patient there's a fair chance that this is is a Hemangioma. So someone's doing a contrast. This is not me doing it. I'll take my. I will take no responsibility for this exam. But you have the lesion down there. And obviously the matching on the contrast side and you can't see very much the report on this said there's no contrast enhancement in the arterial phase. There might be a washout in the late phase and mild washout, so we're a little bit uncertain of this, so the patient came back. Where we used proper settings and transducer and software combination that would actually penetrate and now you can see we have a clear arterial enhancement and in the late phase we have a clear washout so that went for a biopsy and it turns out the patient has an HCC in a completely healthy liver. As far as we know, but that could have been missed if we did not have the ability to penetrate properly into the deeper portions of the liver, both with B mode. In contrast. Another situation where where being able to use a linear transducer helps. This is a liver Abscess. Diagnosed on CT came to ultrasound for drainage. And you can see the difference with with the curved array on on your left and linear transducer on the right. And when we have the really on the curved array as well, but definitely on the linear transducer resolution with slightly suspicious, because this doesn't quite look like a liver Abscess, that's clear fluid, it's not as gunky as it normally is in there, so we gave contrast. Again with the linear transducer to have better spatial resolution, and if you look in in this area here you can see the fluid collection that was seen as an Abscess, but where I pointed you can also see that there's a blood vessel that is thread, thread and thin as a thread, and it seems to be the compressed, so we actually call them up and say we think this is cholangiocarcinoma. That is the blocking the ball ducts from from segment 2, and you can see the lesion and still image and we're talking about the cholangiocarcinoma and the size of 6 by 10 millimeters. Find out. We found it because it blocks the bile ducts upstream, so to speak, but this is what we can do when we have this sort of image resolution. And just another example where it helps. This is a scan of the gallbladder to rule out gallstones done by a resident and she came to me and said, look, this looks a bit suspicious. Is it OK if I give contrast narset fine, give contrast, use the linear transducer and this is what we come up with. We come up with polyps that are more than one centimeter and that enhance the contrast. So this gallbladder was out within three weeks and. Histology said serious displeasure. She's this is here year old, so she's fine by now. You can use linear transducers. Again linear transducer for in the area of the pancreas and and I mean you can you can get images like this if you get an ultrasound model, but I assure you these are clinical patients. These are not. You can have this fantastic spatial resolution in the pancreas in standard patients. If you can just avoid the gas. And this is an example. If you look down here, this is the distal bile duct. I've cropped this image, so we're actually at a depth of 9 centimeters. But what you can see here is a little echo, bright echo of the gallstone and you can see the dilated common bile duct and you can see the thickened wall where the stone has been irritating the bowel duct. An answer, so this was actually so much that we said maybe we should have a look at this when the stone is out. It could be irritation from the stone, but it could be a distal tumor as well, but it disappeared when the stone was out, but we did see it. Another patient where CT has seen a dilatation of the duodenum. As you can see on the left and the image where there's fluid in the transverse duodenum going up to to something that seemed solid on CT. It's been Barb City couple of times on ultrasound and you can't really. You can see where where the dilatation stops on the curved array, ultrasound if you switch to a linear transducer, can see the little pathological lymph nodes in the mesentery and you can see. Lymph node, their lymph node there. You can actually see where the tumor is here and you can see this area here where where the normal wall layers are not present anymore. So we aimed the biopsy for this bit here which gave a diagnosis of adenocarcinoma. Again, you need. If you're into, hit something, you need to be able to see it, and the curved array transducer and the CT only saw where the dilatation stopped basically. Another, this is an MRI. You see the IPM in in the in the pancreas. Coming in there. Linear transducers show the same thing and with fantastic spatial resolution, and you can do this again with contrast. This gives you the ability you can see thin septations with small vessels, but there's no. There are no solid components, nothing here that looks like malignancy coming up. And here again, quite deep into the patient. You can still make out the thickened wall of the common bile duct in the patient with sclerostin colon GITIS. And again you can. You can see it. Also you can see the contrast enhancement in in the thickened wall there. Now this is a patient where where. She has cirrhosis of the liver. You have a lesion in on the MRI up there and the query again is can we do a microwave ablation? And again we need to be able to see it if we're going to hit it and with standard transducer we can't see it. With with the deep abdominal transducer again you can see we lose special spatial resolution, but we have a uniform image throughout the liver. Still, we can't quite make out where that lesion is, so we use fusion. And my guess would be that this is the lesion diffusion points us to that area where you have the little turquoise ring, but I think it's up here and when we give contrast with the deep abdominal transducer we can see it. We can see the arterial enhancement and I've slowed. I've slowed the. The speed of this clip down a little bit so I have time to explain to you or remind you that when you do fusion, don't expect things to match down to millimeter 'cause it never will, especially not in a patient that is so as difficult to scan as this patient is, but at least the fusion gets us to the right area and there we can. In contrast on a deep abdominal transducer we can see the lesion, which means we can. We can treat it. Just rounding off with pointing out that this goes for other patients as well. Here you have an MRI with an Abscess in left, so as muscle and one of our muscular skeletal colleagues very kindly said. I'm sure ultrasound can put a drain into that. One. Trouble is, the patient weighs 140 kilos. And and it's. Quite a distance in so I have to admit I brought to pay, told the nurses, bring the patient down. We can't say no without trying, but we're not going to be able to do this so don't waste extra time in the booking rotor. Just bring the patient down for a basic ultrasound and they will say no. But scanning with the transducer with good penetration it really looks as if there is something in that so as muscle. And giving contrasts, it's fairly obvious that you have you have hyperemia in the service muscle around the Abscess, and you can delineate where the Abscess is. So we did end up putting a drainage into that, and pus came out. So in in conclusion, I would say that modern transducer technology, it's like an unexpected race in salary. It's there you didn't know you had it all of a sudden is there and you can use it for something you want need, or maybe even things you didn't know you needed. Like better penetration in large patients or a better spatial resolution in standard patients. So thank you for paying attention and have a good day, bye.

IOL4 •ABDOMENANI DAX SUS. IOL4 DAX Unknown LUN LUNCH 2020-01-09 •ABDOMENANI •ABDOMENAN3 •ABDOMENAN TIB:o.oo 21.0128-15:14:. 21.0128-15:14:... 2019-09-25 1 0=0.92 cm 11:36 11:24 •ABDOMENAN3 •ABDOMENAN 21/01/28 TIB:O.56 TIB:O.78 2019-09-25 10124 15:15 15:16 LUN CONCLUSION TIS:o.48 1124 TIB:O.48 TIC:2.958 TIB:O.489 TIC:O.OI TIC:O.OO TIS:O.OO TIS:o.OO TRANSDUCERS TIC:2.88 TIS:O.589 TIC2.88 TIB:O.OO IOL4 LUN THERE IS NO SUCH THING AS A FREE 0=0.92 cm •ABDOMENAN 2019-0508 2019-05085 Ml:O.14 TIB:O.956 TIB:O.589 TIB:O.58 Ml 0.14 TIS:o.48 •ABDOMENAN 15:46 TIB_OOO TIB:O.OO 1124 TIB:o.956 TIS:O.956 Ml:O.23 12fps •ABDOMENAN TIB:O.OOI Ml:1.12 TIC.o_OO TIC:2.589 TIC:1.75 •ABDOMENAN3 MI:1.05 Ml:1.02 IOL4 LUNCH TIC:1.73 TIC.OOI TIC:O.OI Ml:l .01 Ml: 1.02 14fps 0.4% *ABDOMENAN 28fps 15 fps 18fps 17fps TIB.o.56 0 01 20fps 1 9fps 8 fps 18fps TIB:O.OO •ABDOMENAN3 TIC 285 TIC:2.89 TIC:2.88 Ml 013 MI:012 23fps 0.79% 95% 98% 25 fps Ml: 1.02 95% 14fps Ml:O.23 Ml:023 Ml:O.023 20 TIS:O.OO 001 29fpS DSO. 56 Ml 023 Ml 013 10fps 29 fps 8 fps Ml 0.14 95% 98% Low 29 fps 28fps 15 fps 1 9fps 25 fps 14 fps 14 fps TIS:OOO 0 00 063% Low M1023 149fps 12fps 24 fps 149fps 8 fps 2 fps 1 9fps OdB/DR60 Ml 013 Ml 0.14 0 14 0.79% MIO 23 0 00 H Mid 18fps 20 28fps 149fps OdB/DR70 OdB DR65 High frequency = good spacial resolution OdB/DR65 13fps 2 fps 12fps H Low Low Contrast 0.79% 079% H Mid OdB/DR60 OdB/DR70 Low Contrast -3dB/DR70 O3dB/DR70 20 OdB/OR60 Low frequency = good penetration High frequency = good spacial resolution 1540 Low OdB/DR70 OdB/DR60 Contrast OdB/DR65 Low Contrast OdB/DR70 OdB/DR60 MapC/T5 OdB/DR70 OdB/DR60 OdB/DR70 But... „ better transducer technology = • Deeper with curved array .. ...or.... Linear transducer at abdominal depth Curved array Vector Linear Low MHz Low MHz High MHz 1540 18cm 16cm 5.5cm 5.5cm 9.5cm 16cm 5.5cm