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Correspondence Luigi Bolondi, M.D. Department of Digestive Diseases and Internal Medicine, University of Bologna Bologna Italy luigi.bolondi@unibo.it The introduction of a new diagnostic tool into the clinical practice has always been a matter of discussion in the medical literature, both by clinicians and health caremanagers. There is generally a first phase characterized by enthusiasm and optimism of the authors performing and proposing the new technique, who generally report convincing results that appear significantly better than those achieved by previous techniques in the same field. The counterpart of this optimism is frequently the skepticism of the majority of clinicians not directly involved in the technique. The subsequent phase, often occurring many years later, is characterized by a more balanced evaluation leading, finally, the scientific societies to produce clinical guidelines, in which a quite general agreement about the advantages and limitations of the technique and its diagnostic accuracy has been reached. This progressive adjustment seems to be particularly complicated and much debated for new advances in ultrasound technology, starting from the introduction of real-time and pulsed and color Doppler and continuing to the recent advent of ultrasound contrast agents (UCAs). It is my opinion that, as far as the ultrasound technology is concerned and, in particular, the use of UCAs, the skepticism and the lack of confidence reported in the literature by nonultrasound-experts, both radiologists and clinicians, has been far greater than for any other technique. Nevertheless, the use of UCAs and the role of contrast-enhanced ultrasound (CEUS) have nowadays been largely accepted in clinical practice, and the technique has been implemented in most centers for more than a decade. However, CEUS is still waiting for a definite allocation in the diagnostic armamentarium, particularly with respect to computed tomography (CT) scans and magnetic resonance imaging (MRI). Experts in ultrasonography have the feeling that this technique truly represents a great revolution, especially for the diagnosis of liver diseases, allowing in a very quick, simple, and economic way, to provide findings similar to or sometime superior to those obtained by the more sophisticated and expensive CT scans and MRIs, whose availability is andwill remain limited. This revolution, however, has not yet been universally understood and acknowledged and, as a consequence, the application of CEUSworldwide is extremely variable. It is worth remarking that the advantages of CEUS have already been extensively reported in the literature of the past decade. Among them, its costeffectiveness has to be emphasized, especially now, when economic resources face the increased medical and health bills. An imaging technique (CEUS) with a diagnostic accuracy for the characterization of hepatic tumors of about 90% to 92% [19, 23], comparable to the rates of CT and MRI, that costs less to the national health system, also considering cases of inconclusive diagnoses where another imaging technique is required [10, 16–18, 21] is now available for clinicians. Therefore, why to date has its use not been strongly encouraged by all scientific societies and health care providers and accepted by the whole clinical community? Many reasons underlying the variability of use of CEUS may be searched and analyzed. From the clinical standpoint they include the fact that UCAs were introduced into the clinical practice significantly later than CT and MRI contrast agents, and therefore their contribution has not been immediately appreciated because similar results, with more readable images, could already be obtained by those techniques. Furthermore, most clinicians are resistant to accept changes in their own practice, and they still consider CEUS as something that has been artificially added to CT and MRI, but actually is unable to replace them. Other important points, which have always negatively affected the judgment of any ultrasound technique, are the defect in the standardization, the operator dependence, the variability of results related to the physical characteristics of any individual patient and, last but not least, the difficulty in the interpretation of images by nonexperts, in comparison to CT and MRI. All these points are again a problem for CEUS. These issues play an important role when clinicians without personal experience in ultrasound are included in the panel of experts requested to produce practical guidelines in which recommendations are based on data coming from the literature and expert opinions: for the latter point, personal expertise in ultrasound is more important than it is in any other diagnostic technique. Added to these issues, there is also the problem of registration for UCAs, which has not yet been achieved in some important countries such as the United States and which is difficult to understand based on a strictly medical evaluation of

The Appropriate Allocation of CEUS in the Diagnostic Algorithm of Liver Lesions: A Debated Issue