The real capabilities of contrast-enhanced ultrasound in the characterization of solid focal liver lesions

Contrast-enhanced US (CEUS) using intravenous agents is a rapidly evolving field even though the main clinically recognized application is the characterization of focal liver lesions. Several reports have described the improvement provided by CEUS in the characterization of focal liver lesions in comparison to unenhanced US. CEUS with low transmit power insonation allows the real-time assessment of focal liver lesion contrast enhancement and vascularity during the different dynamic phases after injection of an intravenous contrast agent. CEUS allows the accurate characterization of focal liver lesions as benign or malignant based on the lesion contrast enhancement pattern during the arterial phase and lesion vascularity during portal-late phase in comparison to the adjacent liver parenchyma. During the portal-late phase, benign lesions present prevalently a sustained contrast enhancement with hyper or isovascular appearance to the adjacent liver while malignant lesions present prevalently microbubble washout with hypovascular appearance. On the other hand, the histology of focal liver lesions can only be confidently predicted in selected cases by CEUS, as in liver haemangiomas presenting typical nodular peripheral enhancement with subsequent centripetal fill-in and focal nodular hyperplasia with central spoke wheel-shaped contrast enhancement