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July 26, 2019 — RadioGraphics

By Shuchi K. Rodgers, MD

Department of Radiology, Einstein Medical Center, Philadelphia, Pennsylvania, Baltimore, Maryland

CEUS can play a crucial role in patients with HCC who undergo ablation. Bansal et al have written a clear and compelling article describing their use of CEUS for preprocedural planning and postablation imaging. In their algorithm, focal regions of APHE diagnosed at postablation CEUS are re-treated during the same session, leading to decreased tumor recurrence rates. Considering that recurrence rates after ablation can be as high as 70% within 5 years, the approach outlined by Bansal et al offers the potential for a significant reduction in these rates. While their approach adds time to the initial procedure, the overall reduction in time, costs, and number of repeat ablation procedures undoubtedly improves patient care.

Other studies support the use of CEUS after ablation to reduce the volume of residual tumor. In one series involving 64 ablations, the residual tumor rate was 0% in the group of patients who underwent CEUS immediately after ablation versus 16.7% in the non-CEUS group. In another series involving 148 HCCs in 93 patients treated with RFA, intraprocedural CEUS depicted residual tumor in 34 (37%) patients, who underwent an additional ablation during the same treatment session. In that study, complete ablation was achieved in 88 (95%) of these patients 24 hours after the treatment session, translating into a 21.9% reduction in costs to treat the entire patient sample.

Bansal et al also describe their successful integration of CEUS with CT and MRI for secondary surveillance. Their protocol calls for performing MRI 1 month after treatment and subsequent imaging at 3-month intervals, alternating between CEUS and MRI (or CT) for the first 2 years.

In summary, the challenges encountered in imaging and treating HCC necessitate the use of all available diagnostic and therapeutic tools to provide the best outcomes for patients. In their article, Bansal et al (1) describe methods that are undeniably beneficial for patients. In their hands, CEUS after ablation and for surveillance has presumably reduced rates of residual and recur-rent tumor and ultimately decreased costs, time, and number of procedures. These authors are to be congratulated for developing this expertise and presenting a clear template that other groups may begin to incorporate.

Author Response

Dr Wilson responds (for the author group): We are grateful to RadioGraphics for the decision to publish our article, “Contrast-enhanced US in Local Ablative Therapy and Secondary Surveil-lance for Hepatocellular Carcinoma,” and the choice of a wonderful CEUS enthusiast to write a commentary on this work. Dr Shuchi Rodgers, of Einstein Medical Center in Philadelphia, has ap-propriately acknowledged the incredible potential of CEUS to contribute to the management of patients with HCC. Her intention, and that of her interventional radiology colleagues, to implement our CEUS protocols for ablative therapy is perhaps the greatest compliment.

My introduction to the field of radiology at the University of Calgary began 12 years ago, in 2007, following a successful venture into liver CEUS in the prior 7 years at the University of Toronto. Very shortly after my arrival at the University of Calgary, my participation in weekly multidisciplinary hepatobiliary rounds motivated me to introduce CEUS into every aspect of patient management for HCC. Although this implementation began initially with the use of CEUS for problem solving—namely, addressing cases with indeterminate CT and MRI results—it quickly evolved to include all aspects of evaluation, including initial liver surveillance of high-risk populations and CEUS-based diagnosis of identified liver nodules. However, it was the inclusion of CEUS in all aspects of ablative therapy, including preprocedural planning, procedural guidance, and immediate postprocedural evaluation, that proved to be the most exciting and challenging. Today we have a team of expert sonographers, a willing group of interventional radiologists and referring hepatologists, and a growing team of radiologists with interest in acquiring skills to perform CEUS and interpret CEUS findings.

I am grateful to Dr Kelly Burak, our senior hepatologist who runs our hepatobiliary clinic, for his support of the use of CEUS for secondary surveillance of patients following their initial therapy. The confirmation of suspicious results by means of integration of CEUS with MRI enables reduced time to therapy and improved patient management. To borrow the last line from Dr Rodgers’ commentary, “I hope that readers will be convinced to add this examination to their practices…. If you are not yet performing CEUS, what are you waiting for?”

*Extract reproduced with acknowledgement and thanks to Radiological Society of North America and its RadioGraphics publication.
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