Kassa Darge, MD, PhDProfessor of Radiology and Surgery
Perelman School of MedicineUniversity of Pennsylvania
Radiologist-in-Chief & William L. Van Alen Endowed Chair
Department of RadiologyChildren‘s Hospital of Philadelphia (CHOP)
Philadelphia, USA
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CONTRAST US RESEARCH GRANTS ▪National Institutes of Health [NIH]
▪Radiological Society of North America [RSNA]▪Society of Pediatric Radiology [SPR]
▪The Thrasher Foundation▪The Helfer Society
▪ Institute for Translational Medicine and Therapeutics [ITMAT] Grant▪Master of Science in Translational Resarch [MTR] Grant
▪The Foerder Grant▪Philips Heathcare
▪Siemens Healthineers▪Lantheus Medical Imaging
▪Bracco Diagnostics Inc.▪Bracco Suisse S.A, Geneva, Switzerland
CENTER FOR PEDIATRIC CONTRAST ULTRASOUND [CPCU]
Department of RadiologyChildren’s Hospital of Philadelphia
partly supported byBracco Diagnostics Inc., Monroe Township, NJ, USA
Pediatric
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
Susan Back, MD | Sudha Anupindi, MD
Misun Hwang, MD | Ryne Didier, MD
Aikaterini Ntoulia, MD, PhD | Anush Sridharan, PhD
Laura Poznick, AAS, RDMS | Trudy Morgan, BS, RDMS
All CHOP sonographers
CHOP referring physicians
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
Objective
•Describe the utility of contrast enhanced ultrasound [CEUS] for genitourinary applications in pediatrics
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS for GU imaging
•No nephrotoxicity•Multiple injections in one examination•Complete contrast elimination in 20 minutes
•No radiation
•Safe
•Reduce need for sedation
•Problem solving tool
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
US contrast agents
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
US contrast agents
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
US contrast agents
•500-600 million microbubbles/ml suspension
•Microbubbles resonate during US •Enhance sound reflection
•US software background subtraction
•Microbubbles remain intravascular•Depicts blood flow
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
Administration routes of US contrast agents
•Intravenous•Intravesical•Intracavitary
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
Safety of US contrast agents: INTRAVENOUS
2012 Dec;42(12):1471-80
Safety of US contrast agents: INTRAVENOUS
Number of PATIENTS 1707
Number of INJECTIONS 1891
Number of ADVERSE EVENTS 11
Percentage of adverse events/injections 0.58%
TYPES OF ADVERSE EVENTS
Serious: 1- anaphylactic reaction 1
Minor: 10- taste alteration 3
- urticaria 2
- nausea 2
- tachycardia 1
- hyperventilation 1
- hypertension 1
- single wheal 1
SonoVue® [Lumason ®]
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
Safety of US contrast agents: INTRAVESICAL
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
▪ 26 Dysuria
▪ 15 Transient macrohematuria
▪ 3 Abdominal discomfort/pain
▪ 2 Anxiety/crying
▪ 2 Urinary retention
▪ 1 Frequency
▪ 1 Blood/mucous discharge
▪ 1 Perineal irritation
▪ 1 Urethral pain
▪ 1 Urinary tract infection
▪ 1 Vomiting
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
Safety of US contrast agents
•High safety profile
•IV: transient minor adverse events
•IV: anaphylactic reaction very rare
•Code cart near US
•Intravesical adverse events: bladder catheter
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
Current pediatric GU applications of CEUS
•Kidney
•Testes
•Voding urosonography and Urethrography
•Retrograde sonourethrography
•Genitography
•Interventions
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the kidney
NORMAL KIDNEY
•Arterial phase 20 to 40 seconds Cortex then medulla
•Homogeneous 45 to 120 seconds
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the kidney: INFECTION
•Pyelonephritis: Hypoechoic•Abscess: Anechoic
•Infection: Bulge •Infarction: No bulge Fontanilla et al 2012 Abdom Imaging 37:639-646
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the kidney: INFECTION
▪ 11-year-old boy▪ Outside CT▪ Pyelonephritis
Left Kidney
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the kidney: INFECTION
Power Doppler
▪ 2 days after the CT
Left Kidney
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the kidney: INFECTION
Left Kidney
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the kidney: INFECTION
▪ 2-week follow-up6 months later
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the kidney: MASS
Solid or cystic
•CEUS more sensitive than CT - Shows blood flow in
hypovascular lesions- Shows blood flow in
septations and solid components
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the kidney: MASS
•1018 lesions•306 definite dx •139 malignant
•712 followed up to 10 years
Right KidneyD e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the kidney: MASS [cystic]
▪ 16-year-old boy▪ back pain▪ urinary incontinence
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the kidney: MASS [cystic]
Right KidneySurgery → cystic nephroma
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the kidney: MASS [solid]
▪ 7-year-old boy▪ History bladder
exstrophy▪ Incidental finding
Left Kidney
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the kidney: MASS [solid]
Left Kidney
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the kidney: MASS [solid]
Left Kidney
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the kidney: MASS [solid]
Surgery →renal cell carcinoma
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the kidney: MASS [pseudo]
▪ 17-year-old female▪ Recurrent pyelonephritis▪ Renal mass?
InitialFollow-up
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the kidney: MASS [pseudo]
No renal massHypertrophied column of Bertin
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the kidney: TRAUMA
• Stable blunt abdominal trauma
• Limitation collecting system injury
CEUS = CT
CEUS > US
CEUS = CT
CEUS > USMissed 26/67
parenchymal
lesions
Prospective 18 children
Sensitivity
US 45%
CEUS 86%
CT 100%
Missed 2/21
parenchymal
lesions
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the kidney: TRAUMA
▪ 16-year-old boy▪ kneed in the abdomen [baseball]
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the kidney: TRAUMA
perinephric collection
▪ 2 days later Hb 11 g/dL → 8 g/dL
Right Kidney
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the kidney: TRAUMA
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the kidney: TRAUMA
active bleeding
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the kidney: TRAUMA
▪ 1 month follow-up
Right Kidney
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the testes
•CEUS as a problem solving tool
•Malignant pattern - early enhancement with washout
• Small tumors color Doppler may not show flow
• Improved diagnostic accuracy incidental testicular lesions
• Fracture lines and contour abnormalities better depicted
• Torsion - Doppler artifact or arterial pulsation from the contralateral testis Valentino et al. 2011 Eur Radiol 21:1831–1840 37
Huang et al. 2012 Br J Radiol 85:S41-53Lock et al. 2011 Urology 77:1049-1053
Isidori et al. 2014 Radiology 273:606-61
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the testes▪ 16-year-old boy▪ scrotal swelling 2 weeks after straddle injury
Right Testis
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the testes
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
CEUS of the testes Surgery →Testicular rupture & ovotestis
Right Testis
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
ceVUS: contrast enhanced Voiding Urosonography
• Compared with voiding cystourethrography [VCUG] and radionuclide cystography [RNC]
• ceVUS detects more vesicoureteral reflux
• ceVUS detects higher grades of reflux
VCUG: 71% Grade I > ceVUS: Grade II or higherDarge K 2008 Pediatr Radiol 38:54-63
> 10% more VUR
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
ceVUS: contrast enhanced Voiding Urosonography
Bladder Left Kidney
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
ceVUS: contrast enhanced Voiding Urosonography
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
ceVUS: contrast enhanced Voiding Urosonography
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
ceVUS: contrast enhanced Voiding Urosonography
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
ceVUS: contrast enhanced Voiding Urosonography
1 mo boy9 yo girl
Urethrosonography: Transperineal
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
ceVUS: contrast enhanced Voiding Urosonography
Urethrosonography: Suprapubic
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
ceVUS: contrast enhanced Voiding Urosonography
▪ Posterior urethral valve
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
Contrast enhanced retrograde urethrography
• In place of fluoroscopic retrograde urethrography [RUG]
• Direct visualization of urethra
• Intraoperative performance
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
Contrast enhanced retrograde urethrography
▪ 17-year-old boy▪ difficult voiding
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
Contrast enhanced retrograde urethrography
▪ Intraoperative US
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
Contrast enhanced retrograde urethrography
▪ Intraoperative US
Bulbar urethral stricture
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
Contrast enhanced genitosonography
▪ In place of fluoroscopic fistulography▪ Direct visualization of different cavities▪ Easier examination field▪ Multiple fillings not a limitation
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
Contrast enhanced genitosonography
V
B
U
▪ 5-month-old girl▪ Congenital adrenal
hyperplasia▪ Disorder of sexual
differentiation
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
Contrast enhanced genitosonography
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
Contrast enhanced genitosonography
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
Contrast enhanced genitosonography
V
B
U
V
B
U
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
Interventional GU contrast US
• In place of fluoroscopy
•Biopsy• Improve conspicuity of lesion• Target viable part of tumor and not necrosis
•Guide nephrostomy tube
•Determine connection of cysts
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
Interventional GU contrast US
▪ 13-year-old girl, left upper pole renal cyst
Left Kidney
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
Interventional GU contrast US
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a
TAKE-HOME-POINTS
▪ Contrast US: high safety profile▪ GU contrast US:
IV, intravesical, interventional▪ Multiple advantages▪ Numerous indications▪ Expansion of indications in the future
D e p a r t m e nt o f R a d i o l o g y, C h i l d r e n ’s H o s p i ta l o f P h i l a d e l p h i a