Updates in Contrast-Enhanced Ultrasound VHL Symposium 2020 Emily - - PowerPoint PPT Presentation

Updates in Contrast-Enhanced Ultrasound

VHL Symposium 2020 Emily Chang October 31, 2020

Disclosures

• Contracts with Lantheus Medical Imaging (makers
• f Definity, ultrasound contrast agent)

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Objectives

• Rationale for investigation
• Review of contrast-enhanced ultrasound (CEUS)
• Update in CEUS policies
• Clinical CEUS procedure

» Clips

• CEUS as surveillance in VHL?

» Challenges » Benefits » Clips

• CEUS pancreas

Active Surveillance Changes

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VHL.org

(Borrowed from Dr Daniels’ slides)

Gadolinium - safety issues

• Gadolinium very low adverse event rate
• 2006: Nephrogenic sclerosing fibrosis reported in

patients with severe kidney disease

• Stage 4 and higher kidney disease requires informed

consent -> RARE!

• “Group 2” agents thus far no reports of NSF

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Woolen, et al. JAMA IM, Dec 2019

Gadolinium – safety issues

• 2015: Gadolinium deposition disease reported, but

clinical significance not clear

• 2017: FDA issues class warning

» no direct linkage to adverse effects » requires New Patient Medication Guide » requires manufacturers to conduct animal and human studies to further assess safety

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Borrowed from Dr Sven Glasker’s slides

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Gadolinium – comfort issues

• Long exam
• Cumbersome
• Loud noises
• Cold/Hot
• Personal experience: more difficult as I age
• Cost $$$

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Ultrasound

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Advantages

• Accessibility
• Cost
• Patient tolerability
• Lack of radiation

Disadvantages

• Single organ imaging
• User dependent
• Despite better

resolution, interpretation is not intuitive to clinicians

• Lack of contrast

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Contrast-enhanced Ultrasound (CEUS)

• Microbubble contrast agents
• Blood flow & tissue perfusion
• Advantages: cost efficient, safe, images in real time
• Disadvantages: Not yet FDA approved for kidneys,

short enhancement and circulation time, single plane

Perflutren lipid microspheres

Definity

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Sulfur hexafluoride lipid microspheres

Lumason (Sonovue)

Perflutren protein microspheres

Optison

What makes Microbubbles Different from Gadolinium (or iodinated contrast)

• Nonlinear response to ultrasound not produced by

tissue

» Microbubble echoes can be separated from tissue

• No extravasation

» Reflect blood flow

• Can be destroyed with ultrasound – FLASH

» Bubble signal can be cleared and reperfusion visualized

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Microbubble clearance

• After minutes of circulation, breathed off
• NOT cleared through the kidney
• NOT nephrotoxic

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Update in CEUS

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CEUS indications/applications grow

• Liver
• Kidney (mass and in place of VCUG)
• Acute coronary syndrome
• Vascular
• GI
• Pregnant women!
• Brain
• Pancreas

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Billing

PROCEDURE BASE CODE CHARGE ADD-ON CHARGE ADD-ON CHARGES PHARMACY CHARGE Lesion CEUS

76978 Ultrasound, targeted dynamic microbubble sonographic contrast characterization (non- cardiac); initial lesion 76979 Ultrasound, targeted dynamic microbubble sonographic contrast characterization (non-cardiac); each additional lesion with separate injection 76705 Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)

• Liver

76775 Ultrasound, retroperitoneal (eg, renal, aorta, notes), real time with image documentation; limited

• Kidney(s)

76770 Ultrasound, retroperitoneal (eg, renal, aorta, notes), real time with image documentation; complete

• Kidneys/Bladder

Q9950 for MLs used Q9950- with JW modifier for MLs discarded

What Can the Patient Expect?

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CEUS process at UNC

• IV: 20g or larger, preferably in larger AC vein
• Localizing images
• Pre-scan images reviewed with radiologist and

sonographer

• Real-time imaging

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Timing

• IV placement to IV d/c: 1 hr
• Actual imaging: 5-20 min
• Time to result: Same day

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Case #1

• 51 yo man with ESKD on PD for 2 years, and

recently started on HD

• Minimal urine
• 3 cm L kidney mass seen on B-mode US

CEUS

“Peak Hold”

Case #2

• 63 yo woman with PCKD
• H/o partial L nephrectomy for RCC with resultant

stage 4 CKD

• Referred for concerning CT scan

CEUS – B-mode sweeps

Lesion 1

Lesion 2

Case #3 – Liver imaging in a CKD patient

• 42 yo woman with FSGS and TB kidney
• Incidental finding on MRI – hepatic lesion
• Cr 3-3.5, eGFR 13-18

CEUS

CEUS for VHL surveillance?

Challenges

• Usually a targeted study
• Not been studied as a

surveillance tool

• User dependent
• Not all centers can do it
• Single organ imaging

Benefits

• No gadolinium or iodinated

contrast exposure (safe if CKD)

• Cheaper
• Well-tolerated
• Excellent sensitivity with

adequate training

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CEUS VHL study at UNC

• Unable to convert DICOM to viewable clip

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Pancreas?

• In order to be truly effective, will need to be able to

assess pancreas too

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D’Onofrio, European Journal of Radiology 2015

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Conclusion

• CEUS shows promise as a surveillance tool for kidney

lesions

• VHL is a ideal disease in which to test this
• May reduce exposure & cost and increase tolerability

» Plan to assess patient satisfaction

• Positive findings in this area have potential to

increase CEUS applications

Acknowledgements

• Rachel White
• Kennita Johnson
• Terry Hartman
• Shanah Kirk
• Katie Johnson
• Luna Hilaire (Lantheus)

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Thank you for your time!

• Questions?
• Emily_chang@med.unc.edu
• @kimchikidney

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5 µm

• microbubbles
• gas core
• highly compressible
• stabilizing shell (lipid, albumin)
• biocompatible
• Size: 1-5 microns, similar to RBC
• activated by mixing
• injected into bloodstream

2 µm

Ultrasound contrast agents