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The present, updated document describes the fourth iteration of recommendations for the hepatic use of contrast enhanced ultrasound (CEUS), first initiated in 2004 by the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). The previous updated editions of the guidelines reflected changes in the available contrast agents and updated the guidelines not only for hepatic but also for non-hepatic applications.The 2012 guideline requires updating as previously the differences of the contrast agents were not precisely described and the differences in contrast phases as well as handling were not clearly indicated. In addition, more evidence has been published for all contrast agents. The update also reflects the most recent developments in contrast agents, including the United States Food and Drug Administration (FDA) approval as well as the extensive Asian experience, to produce a truly international perspective.These guidelines and recommendations provide general advice on the use of ultrasound contrast agents (UCA) and are intended to create standard protocols for the use and administration of UCA in liver applications on an international basis to improve the management of patients.

The first edition of the guidelines for the use of ultrasound contrast agents was published in 2004, dealing with liver applications. The second edition of the guidelines in 2008 reflected changes in the available contrast agents and updated the guidelines for the liver, as well as implementing some nonliver applications. The third edition of the contrast-enhanced ultrasound (CEUS) guidelines was the joint World Federation for Ultrasound in Medicine and Biology-European Federation of Societies for Ultrasound in Medicine and Biology (WFUMB-EFSUMB) venture in conjunction with other regional US societies such as Asian Federation of Societies for Ultrasound in Medicine and Biology, resulting in a simultaneous duplicate on liver CEUS in the official journals of both WFUMB and EFSUMB in 2013. However, no guidelines were described mainly for Sonazoid due to limited clinical experience only in Japan and Korea. The new proposed consensus statements and recommendations provide general advice on the use of Sonazoid and are intended to create standard protocols for the use and administration of Sonazoid in hepatic and pancreatobiliary applications in Asian patients and to improve patient management.

Contrast-enhanced ultrasound (CEUS) is an imaging modality applied in a broad field of medical specialties for diagnostic uses, guidance during biopsy procedures and ablation therapies and sonoporation therapy. Appropriate training and assessment of theoretical and practical competencies are recommended before practicing CEUS, but no validated assessment tools exist. This study was aimed at developing a theoretical multiple-choice question-based test for core CEUS competencies and gathering validity evidence for the test. An expert team developed the test via a Delphi process. The test was administered to medical doctors with varying CEUS experience, and the results were used to evaluate test items, internal-consistency reliability, ability to distinguish between different proficiency levels and to establish a pass/fail score. Validity evidence was gathered according to Messick's framework. The final test with 47 test items could distinguish between operators with and without CEUS experience with acceptable reliability. The pass/fail score led to considerable risk of false positives and negatives. The test may be used as an entry test before learning practical CEUS competencies but is not recommended for certification purposes because of the risk of false positives and negatives. publishedVersion

The evolution of ultrasound imaging into a key technology for diagnostic practice has resulted in its incorporation into the education of medical students worldwide. Although the introduction of ultrasound into medical schools’ curricula is relatively recent, training of sonographers and other ultrasound users is mature. Ultrasound is being used in a variety of learning environments and clinical settings, from courses in anatomy and physiology to clinical rotations where medical and other students may scan healthy volunteers or patients, sometimes with little to no supervision. Educators may be apprehensive about a perceived high likelihood that students will encounter unexpected findings during these sessions, which could distress the patient or ultrasound model as well as the student, and result in problems that would be more pronounced if such incidental findings are complex. Policies are needed to address how to manage incidental ultrasound findings that are identified during educational activities. This article summarizes the background and provides a framework for establishing and implementing a well-designed and thoughtful approach for dealing with incidental findings observed in volunteer subjects by medical students during training courses in ultrasound diagnostic scanning. Subject confidentiality should be respected, and review of incidental findings should be transparent without provoking unnecessary anxiety. It is the responsibility of the instructor or supervisor to ensure adequate clinical follow-up if indicated.

Ultrasound is becoming a fundamental first-line diagnostic tool for most medical specialties and an innovative tool to teach anatomy, physiology and pathophysiology to undergraduate and graduate students. However, availability of structured training programs during medical school is lagging behind and many physicians still acquire all their ultrasound skills during postgraduate training.There is wide variation in medical student ultrasound education worldwide. Sharing successful educational strategies from early adopter medical schools and learning from leading education programs should advance the integration of ultrasound into the university medical school curricula. In this overview, we present current approaches and suggestions by ultrasound societies concerning medical student educa-tion throughout the world. Based on these examples, we formulate a consensus statement with suggestions on how to integrate ultrasound teaching into the preclinical and clinical medical curricula.

Introduction Liver metastases from colorectal cancer are common and ablation therapy is a favourable treatment option for selected patients not suited for surgical resection. This study aimed to systematically review the literature and present prognostic factors associated with survival and local recurrence after percutaneous ultrasound-guided ablation treatment. Materials and methods This review is reported according to the PRISMA. PubMed, Embase and Scopus were searched and records were independently screened by two authors, initially on title and abstract and subsequently on full-text basis. The quality of the studies was assessed using the Newcastle-Ottawa quality assessment scale. Results Of 2.882 records screened, 18 studies were included. The median survival was 23 months. One-year survival was median 95% and 3-year survival was median 58%. Complete ablation response and adjuvant chemotherapy produce considerably improved survival and low local recurrence rate outcomes. Conclusion Percutaneous ultrasound-guided ablation technique for colorectal liver metastases provides impressive survival rates for patients not suited for surgical resection. However, there are some factors related to poorer prognosis, which may be considered when selecting patients.

The updated version of the EFSUMB guidelines on the application of non-hepatic contrast-enhanced ultrasound (CEUS) deals with the use of microbubble ultrasound contrast outside the liver in the many established and emerging applications.Die aktualisierte Version der EFSUMB-Leitlinien für die Anwendung von nicht-hepatischem kontrastverstärktem Ultraschall (CEUS) befasst sich mit der Verwendung von Mikrobläschen Ultraschall-Kontrastmitteln außerhalb der Leber in zahlreichen etablierten und neu entstehenden Einsatzbereichen.

Point-of-care ultrasound (POCUS) has become a topical subject and can be applied in a variety of ways with differing outcomes. The cost of all diagnostic procedures including obstetric ultrasound examinations is a major factor in the developing world and POCUS is only useful if it can be equated to good outcomes at a lower cost than a routine obstetric examination. The aim of this study was to assess a number of processes including accuracy of images and reports generated by midwives, performance of a tablet-sized ultrasound scanner, training of midwives to complete ultrasounds, teleradiology solution transmissions of images via internet, review of images by a radiologist, communication between midwife and radiologist, use of this technique to identify high-risk patients and improvement of the education and teleradiology model components. The midwives had no previous experience in ultrasound. They were stationed in rural locations where POCUS was available for the first time. After scanning the patients, an interim report was generated by the midwives and sent electronically together with all images to the main hospital for validation. Unique software was used to send lossless images by mobile phone using a modem. Transmission times were short and quality of images transmitted was excellent. All reports were validated by two experienced radiologists in our department and returned to the centers using the same transmission software. The transmission times, quality of scans, quality of reports and other parameters were recorded and monitored. Analysis showed excellent correlation between provisional and validated reports. Reporting accuracy of scans performed by the midwives was 99.63%. Overall flow turnaround time (from patient presentation to validated report) was initially 35 min but reduced to 25 min. The unique mobile phone transmission was faultless and there was no degradation of image quality. We found excellent correlation between final outcomes of the pregnancies and diagnoses on the basis of reports generated by the midwives. Only 1 discrepancy was found in the midwives' reports. Scan results versus actual outcomes revealed 2 discrepancies in the 20 patients identified as high risk. In conclusion, we found that it is valuable to train midwives in POCUS to use an ultrasound tablet device and transmit images and reports via the internet to radiologists for review of accuracy. This focus on the identification of high-risk patients can be valuable in a remote healthcare facility.

The present, updated document describes the fourth iteration of recommendations for the hepatic use of contrast-enhanced ultrasound, first initiated in 2004 by the European Federation of Societies for Ultrasound in Medicine and Biology. The previous updated editions of the guidelines reflected changes in the available contrast agents and updated the guidelines not only for hepatic but also for non-hepatic applications. The 2012 guideline requires updating as, previously, the differences in the contrast agents were not precisely described and the differences in contrast phases as well as handling were not clearly indicated. In addition, more evidence has been published for all contrast agents. The update also reflects the most recent developments in contrast agents, including U.S. Food and Drug Administration approval and the extensive Asian experience, to produce a truly international perspective. These guidelines and recommendations provide general advice on the use of ultrasound contrast agents (UCAs) and are intended to create standard protocols for the use and administration of UCAs in liver applications on an international basis to improve the management of patients.

This article represents part 3 of the EFSUMB Recommendations and Guidelines for Gastrointestinal Ultrasound (GIUS). It provides an overview of the examination techniques recommended by experts in the field of endorectal/endoanal ultrasound (ERUS/EAUS), as well as perineal ultrasound (PNUS). The most important indications are rectal tumors and inflammatory diseases like fistula and abscesses in patients with or without inflammatory bowel disease (IBD). PNUS sometimes is more flexible and convenient compared to ERUS. However, the technique of ERUS is quite well established, especially for the staging of rectal cancer. EAUS also gained ground in the evaluation of perianal diseases like fistulas, abscesses and incontinence. For the staging of perirectal tumors, the use of PNUS in addition to conventional ERUS could be recommended. For the staging of anal carcinomas, PNUS can be a good option because of the higher resolution. Both ERUS and PNUS are considered excellent guidance methods for invasive interventions, such as the drainage of fluids or targeted biopsy of tissue lesions. For abscess detection and evaluation, contrast-enhanced ultrasound (CEUS) also helps in therapy planning.

US-guided percutaneous biopsy of focal liver lesions (FLL) is a classic interventional procedure performed by almost all radiology units. Typically, an incidental focal finding on US or a focal indeterminate lesion diagnosed on CT, MRI or PET/CT is referred for US-guided biopsy for final diagnosis. The introduction of microbubble US contrast agents has overcome some of the limitations of standard US in diagnosing FLLs by displaying the microvasculature together with the US morphology, which has increased both the sensitivity and the specificity. The combination of CEUS and intervention is facilitated by newer US equipment providing split-screen mode, which displays the CEUS mode alongside the standard US mode simultaneously on a single monitor. The puncture line is displayed in both modes as well as on the monitor. The interventional device (i. e., biopsy needle) is typically best visualized in the standard US mode, while the characteristic tissue pattern in an FLL is typically best visualized in CEUS mode. There are 3 main categories in which CEUS has an impact on US-guided biopsy of FLLs: • CEUS improves the visualization of FLLs • CEUS improves the quality of the biopsy specimen from an FLL • CEUS reduces the need for US-guided biopsy of an FLL In the two first categories, CEUS is utilized simultaneously with US-guided biopsy to ensure correct needle targeting. In the last category, US-guided biopsy of the FLL becomes superfluous as a result of the CEUS examination.

The updated version of the EFSUMB guidelines on the application of non-hepatic contrast-enhanced ultrasound (CEUS) deals with the use of microbubble ultrasound contrast outside the liver in the many established and emerging applications.Die aktualisierte Version der EFSUMB-Leitlinien für die Anwendung von nicht-hepatischem kontrastverstärktem Ultraschall (CEUS) befasst sich mit der Verwendung von Mikrobläschen Ultraschall-Kontrastmitteln außerhalb der Leber in zahlreichen etablierten und neu entstehenden Einsatzbereichen.

The use of CEUS has expanded the field of interventional ultrasound and established new possibilities in patient management and diagnostic capabilities. CEUS is a powerful diagnostic tool due to excellent time resolution and the possibility to keep a suspected lesion in the scanning plane throughout the entire contrast study. This feature frequently results in CT negative metastases being diagnosed with CEUS. CEUS increase procedure success in biopsy of conventional B-mode “invisible” lesions or large tumors with necrosis. CEUS performed before and immediately after ablation procedures greatly improve the success rate. CEUS can be of great value utilized intracavitary during abscess drainage or biliary and urological interventions. Fusion ultrasound is an image application, whereby US images are presented simultaneously with corresponding, previously acquired images obtained from other imaging modalities such as CT, PET or MRI. CEUS and fusion, and especially the combination of the two, has become decisive factors in liver imaging. These technologies increase detection sensitivity, enable immediate diagnosis of malignant versus benign lesion, plus facilitate differentiation between benign lesions such as hemangiomas, adenomas and FNH. The basic advantage of image fusion with ultrasound is the possibility to combine the dynamic features of ultrasound with the virtues of CT and MR imaging. In addition, fusion used in combination with CEUS has a great potential for increasing procedure technique during guiding of interventional procedures US-guided ablation of non-operable malignant liver lesions with RF or MW has become a well-established treatment that can be performed either percutaneously, laparoscopically, intraoperatively, during laparotomy or in combination with liver surgery. Ultrasound remains the most used guiding modality for these procedures for obvious reasons. Dedicated devices for US-guidance of these procedures are rapidly evolving and CEUS and fusion performed before and after the ablation procedure improves the treatment results. In case of non-operability, however, biopsy of lesions seen at CT, PET or MRI remains mandatory to confirm malignancy before chemotherapy or image-guided ablation with RF, MW, cryo or similar techniques. Use of CEUS and fusion may enable biopsy of otherwise ultrasound invisible lesions. Use of CEUS and fusion may change the classic indications for biopsies and reduce the number of diagnostic biopsies. US-guided biopsies, however, will still be required in case of equivocal findings and likely will continue to serve as Gold-Standard. In addition, CEUS may visualize bleeding related to interventional US thus reducing the risk of severe complication. Interventional US has countless applications and recent technological achievements described herein have provided new valuable elements to its use.

This is the second part of the series on interventional ultrasound guidelines of the Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). It deals with the diagnostic interventional procedure. General points are discussed which are pertinent to all patients, followed by organ-specific imaging that will allow the correct pathway and planning for the interventional procedure. This will allow for the appropriate imaging workup for each individual interventional procedure (Long version).

This is the first part of the Guidelines on Interventional Ultrasound of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) and covers all general aspects of ultrasound-guided procedures (short version; the long version is published online).

In pediatrics ultrasound has long been viewed more favorably than imaging that exposes patients to radiation and iodinated contrast or requires sedation. It is child-friendly and diagnostic capabilities have been improved with the advent of contrast-enhanced ultrasound (CEUS). The application of CEUS is indeed promising. However, no ultrasound contrast agent manufactured today is registered for pediatric use in Europe. The contrast agent SonoVue® has recently been approved by the FDA under the name of Lumason® to be used in hepatic investigations in adults and children. This article reviews the literature with respect to 2 specific applications of CEUS in children: 1) identification of parenchymal injuries following blunt abdominal trauma, and 2) classification of focal liver lesions. Applications were chosen through the CEUS guidelines published by the European Federation of Societies for Ultrasound in Medicine and Biology and World Federation for Ultrasound in Medicine and Biology. Literature was obtained by searching Medline and Pubmed Central (using Pubmed), Scopus database and Embase. CEUS proved to be an effective investigation in the hemodynamically stable child for identifying parenchymal injuries and for the characterization of focal liver lesions. CEUS showed comparable performance to CT and MRI with a specificity of 98% for identifying benign lesions and a negative predictive value of 100%. For the applications reviewed here, CEUS holds promising perspectives and can help reduce radiation exposure and use of iodinated contrast agents in pediatrics, thereby potentially reducing complications in routine imaging.

Purpose: This research aims to understand key problems and identify possible solutions in the market for radiology equipment in low- and middle-income countries. Methods and Materials: This paper uses simple descriptive statistics to summarize the results of responses from 574 radiologists from 52 countries surveyed in April-May 2017, and 15 hardware and software vendors from six countries surveyed in September-October 2017. Results: Radiologists surveyed came from both public and private sectors and were drawn from Radiological Society of North America (RSNA) members who, according to the survey results, appear to represent sites with more advanced technology. Virtually all the radiologists worked at sites where both X-ray and ultrasound were available, and the overwhelming majority (93%) had access to CT. Digital technology has gone worldwide: radiologists in all countries reported that digital radiography was either equally or more available than analog technologies. Sixty percent of radiologists said that they were “always” or “often” involved in the purchasing decisions in their institutions, but only 35% reported that they had the final say. According to the radiologists surveyed, the era of donated equipment is ending. Ninety-five percent felt that the disadvantages of donated equipment outweighed the cost savings. Training was a key concern both for radiologists and vendors. Radiologists felt that training was insufficient, materials left behind too complicated, online materials too limited, and follow-up from vendors insufficient. Vendors pointed out that the bidding process often excluded the cost of training and support and that many purchases are made through local distributors and they lack direct contact with vendors. Conclusion: While digital radiology is spreading throughout the surveyed countries, access to advanced imaging remains limited. Donated equipment is no longer a major solution to limited equipment availability. There is an opportunity for vendors and radiologists to work together to ensure that training, service and support are always included in purchases.

Transrectal ultrasound (TRUS), sometimes named endoanal ultrasound, is performed with dedicated endoprobes and in the hands of an experienced user, can represent an indispensable tool in evaluation of anal fistulae and abscesses in the perianal and – rectal region plus staging of anal and rectal cancer. The spatial resolution of TRUS is unsurpassed, however, MRI or CT should be used to provide a complementary overview of the entire region. The anal canal constitutes the distal approximately 4 cm of the bowel system and represents the transition between mucosal lining in the rectum and squamous cell lining of the skin. The ultrasound appearance is dominated by the change in anatomy of the muscular layers of the wall which in this small segment is made up solely of the circular, concentric muscles representing the internal and external anal sphincter. The anal canal is divided into 3 levels relating to the sphincter muscles. In rectum 5 distinctive layers corresponding to the underlying anatomy can be identified with TRUS and correlated to disease. TRUS guided intervention by means of biopsy or drainage can be performed with a rigid US probe as well as with flexible echoendoscopes. The rigid US probe with an end-fire design is optimal for endo-rectal interventions and in most cases can visualize the entire rectum including perirectal structures. With use of a dedicated needle guide mounted on the probe this technique enables precise puncture of most rectal or perirectal target seen on TRUS. TRUS guided biopsy of rectal masses is an important supplement to the conventional endoscopic biopsy if the latter technique does not provide the final diagnosis. Indications are staging of rectal cancer or suspicions of local recurrence. In these cases, a TRUS guided biopsy of the rectal masse with a 1.2 mm needle (18 gauge automatic or semi-automatic biopsy systems) can provide a deep tissue sample that often results in a final histologic diagnosis. In addition, TRUS guided biopsy is an obvious technique to provide histologic or cytologic information about enlarged lymph nodes or other suspicious perirectal masses. TRUS guided drainage of perianal and deep pelvis abscesses or other fluid collections is a safe approach and effective treatment in cases where the transabdominal percutaneous access cannot be utilized because of overlying structures. This technique provides an alternative to other access routes such as transvaginal, transgluteal or transperineal technique Smaller abscesses can often be treated with needle aspiration followed by saline irrigation, whereas larger abscesses may require continuous drainage through a catheter, which can be inserted with Seldinger technique. A preprocedure CT examination of the lower abdomen is recommended to visualize the exact location and size of the abscess in order to optimize drainage strategy.

A scourge from time long past that we thought removed from the surface of the earth has affected humanity again, or more correctly, part of humanity. A misery so all‐embracing that it is incomprehensible to people of the Western world is everyday reality for hundreds of thousands of young women in Africa and other parts of the developing world. A disease by the somewhat strange name of obstetric fistula (OF), also known as rectovaginal or vesicovaginal fistula, 1 afflicts more than two million women in low‐resource countries and the most remote parts of the world, while at the same time is totally absent in high‐income countries. 3 A fistula by definition is a false exit from cavities or tubular structures inside the body to the outside world or in‐between internal structures that arises due to disease or physical damage. An obstetrical fistula is either a connection between the rectum and the vagina that allows stool to pass unhindered or a connection betwen the urinary bladder and the vagina that allows urine to pass. The term ‘obstetric’ derives from the fact that these fistulae are caused by tissue damage due to prolonged labour. To the vast majority in the West it is not even known. However, anyone who has ever visited a medical history museum will probably recall the horror by which one was struck when observing the instruments used for cutting up the (almost always dead) fetus in case of obstructed labour, and with little doubt, at the same occasion thought these doctors must have been some kind of monsters. Little did we know that the condition which called for the use of these cruel instruments still exists and affects thousands of birth‐giving women, mainly in Sub‐Saharan Africa and South Asia every day. Only the instruments, luckily, are no longer in use, but neither is the modern alternative available in these parts of the world. This very, very unlucky scenario causes the unbelievable suffering of millions of women through the complications of OF. Of course today in the West, treatment would involve the timely help of a midwife and, if necessary, a caesarian section performed by an obstetrical surgeon. With this prologue, I wish to emphasise that being a young girl or an adolescent woman living in rural areas of contemporary Africa may very likely mean exposure to several forms of negative discrimination that inevitably decreases odds for leading a prosperous and happy life. Obstetric fistula especially afflicts impoverished girls and women living in remote regions without adequate medical services. Affecting the most powerless members of society, it touches issues related to reproductive health and rights, gender equality, poverty and adolescence.

Gastrointestinal ultrasound (GIUS) is an ultrasound application that has been practiced for more than 30 years. Recently, GIUS has enjoyed a resurgence of interest, and there is now strong evidence of its utility and accuracy as a diagnostic tool for multiple indications. The method of learning GIUS is not standardised and may incorporate mentorship, didactic teaching and e-learning. Simulation, using either low- or high-fidelity models, can also play a key role in practicing and honing novice GIUS skills. A course for training as well as establishing and evaluating competency in GIUS is proposed in the manuscript, based on established learning theory practice. We describe the broad utility of GIUS in clinical medicine, including a review of the literature and existing meta-analyses. Further, the manuscript calls for agreement on international standards regarding education, training and indications.

The intent of this review is to discuss and comment on common clinical scenarios in which contrast-enhanced ultrasonography (CEUS) may play a decisive role and to illustrate important points with typical cases. With the advent of CEUS, the scope of indications for ultrasonography has been dramatically extended, and now includes functional imaging and tissue characterization, which in many cases enable tumor diagnosis without a biopsy. It is virtually impossible to imagine the practice of modern medicine as we know it in high-income countries without the use of imaging, and yet, an estimated two thirds of the global population may receive no such care. Ultrasound imaging with CEUS has the potential to correct this inequity.

Item does not contain fulltext BACKGROUND AND AIMS: EUS-guided FNA or biopsy sampling is widely practiced. Optimal sonographic visualization of the needle is critical for image-guided interventions. Of the several commercially available needles, bench-top testing and direct comparison of these needles have not been done to reveal their inherent echogenicity. The aims are to provide bench-top data that can be used to guide clinical applications and to promote future device research and development. METHODS: Descriptive bench-top testing and comparison of 8 commonly used EUS-FNA needles (all size 22 gauge): SonoTip Pro Control (Medi-Globe); Expect Slimline (Boston Scientific); EchoTip, EchoTip Ultra, EchoTip ProCore High Definition (Cook Medical); ClearView (Conmed); EZ Shot 2 (Olympus); and BNX (Beacon Endoscopic), and 2 new prototype needles, SonoCoat (Medi-Globe), coated by echogenic polymers made by Encapson. Blinded evaluation of standardized and unedited videos by 43 EUS endoscopists and 17 radiologists specialized in GI US examination who were unfamiliar with EUS needle devices. RESULTS: There was no significant difference in the ratings and rankings of these needles between endosonographers and radiologists. Overall, 1 prototype needle was rated as the best, ranking 10% to 40% higher than all other needles (P < .01). Among the commercially available needles, the EchoTip Ultra needle and the ClearView needle were top choices. The EZ Shot 2 needle was ranked statistically lower than other needles (30%-75% worse, P < .001). CONCLUSIONS: All FNA needles have their inherent and different echogenicities, and these differences are similarly recognized by EUS endoscopists and radiologists. Needles with polymeric coating from the entire shaft to the needle tip may offer better echogenicity.

The fifth section of the Guidelines on Interventional Ultrasound (INVUS) of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) assesses the evidence for all the categories of endoscopic ultrasound-guided treatment reported to date. Celiac plexus neurolysis and block, vascular intervention, drainage of fluid collections, drainage of biliary and pancreatic ducts, and experimental tumor ablation techniques are discussed. For each topic, all current evidence has been extensively analyzed and summarized into major recommendations for reader consultation (short version; the long version is published online).

The third part of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Guidelines on Interventional Ultrasound assesses the evidence for ultrasound-guided and assisted interventions in abdominal treatment procedures. Recommendations for clinical practice are presented covering indications, contraindications, safety and efficacy of the broad variety of these techniques. In particular, drainage of abscesses and fluid collections, interventional tumor ablation techniques, interventional treatment of symptomatic cysts and echinococcosis, percutaneous transhepatic cholangiography and drainage, percutaneous gastrostomy, urinary bladder drainage, and nephrostomy are addressed (short version; a long version is published online).

International audience; Initially, a set of guidelines for the use of ultrasound contrast agents was published in 2004 dealing only with liver applications. A second edition of the guidelines in 2008 reflected changes in the available contrast agents and updated the guidelines for the liver, as well as implementing some non-liver applications. Time has moved on, and the need for international guidelines on the use of CEUS in the liver has become apparent. The present document describes the third iteration of recommendations for the hepatic use of contrast enhanced ultrasound (CEUS) using contrast specific imaging techniques. This joint WFUMB-EFSUMB initiative has implicated experts from major leading ultrasound societies worldwide. These liver CEUS guidelines are simultaneously published in the official journals of both organizing federations (i.e., Ultrasound in Medicine and Biology for WFUMB and Ultraschall in der Medizin/European Journal of Ultrasound for EFSUMB). These guidelines and recommendations provide general advice on the use of all currently clinically available ultrasound contrast agents (UCA). They are intended to create standard protocols for the use and administration of UCA in liver applications on an international basis and improve the management of patients worldwide.

The fourth part of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Guidelines on Interventional Ultrasound describes general aspects of endoscopic ultrasound-guided diagnostic and therapeutic interventions and assesses the evidence for endoscopic ultrasound-guided sampling. Endoscopic ultrasound combines the most advanced high-resolution ultrasound imaging of lesions within the wall and in the vicinity of the gastrointestinal tract and safe and effective fine needle-based tissue acquisition from these lesions. The guideline addresses the indications, contraindications, techniques, adverse events, training and clinical impact of EUS-guided sampling. Advantages and drawbacks are weighed in comparison with image-guided percutaneous biopsy. Based on the most current evidence, clinical practice recommendations are given for crucial preconditions and steps of EUS-guided sampling as well as for safe performance. Additionally, the guideline deals with the principles and reliability of cytopathological reporting in endoscopic ultrasound-guided sampling (short version; the long version is published online).

Most institutions perform percutaneous liver biopsy with a post-biopsy patient observation period lasting up to eight hours, which is resource-demanding. This study aimed to evaluate the safety of liver biopsy performed in a fast-track set-up with an only one-hour post-biopsy observation time.Patients referred to our institution underwent fast-track ultrasound-guided 18-gauge Tru-Cut liver biopsy procedures. Each single biopsy procedure was followed by a post-procedure observational period of one hour and an additional focused assessment with sonography for trauma before patient discharge. All patients underwent a clinical follow-up programme at revisit in order to register any delayed onset of major complications.Out of 200 completed biopsy procedures, two major complications were registered post biopsy and they were treated appropriately. All patients were safely discharged from our institution. No fatality or long-term complications were found during this study.The fast-track approach reported herein is a feasible option when adequate patient information is given. Besides the obvious, positive effect on patient logistics and departmental throughput, this approach may also reduce diagnostic work-up time and bring financial benefits. Therefore, we encourage the use of this approach in institutions comparable to our own.not relevant.not relevant.

Background: Neoplasm seeding is a serious complication after liver metastases biopsy. Reported incidences vary between 10% and 19% for colorectal cancer (CRC) and are unknown for breast cancer (BC). The aim of this retrospective study was to determine the frequency of tumor seeding after ultrasound-guided percutaneous biopsy of CRC and BC liver metastases. Material and methods: Unselected liver biopsies performed in the period of 2005–2012 at our institution were extracted from the National Pathology Registry. Medical records including imaging from patients with biopsy-verified BC and CRC liver metastases were retrospectively reviewed. The endpoint was the development of abdominal wall recurrence following liver biopsy. Results: Of total 2981 biopsies we identified 278 patients with CRC and 155 patients with BC biopsy-verified liver metastases. During the median follow-up of 25 months after biopsy (range 3–253 months), no seeding was recorded in patients with BC. Within the median follow-up of 34 months (3–111 months), seeding was registered in 17/278 (6%) of patients with CRC; three patients of 278 (1%) had undoubtedly biopsy-related seeding, which became apparent six, nine, and 26 months after biopsy, respectively; and in nine patients (3%) seeding occurred due to either biopsy or other interventions; and five patients had seeding, which were assessed as a consequence of other invasive procedures than biopsies. The median overall survival of the 17 patients with seeding was 70 months compared to 39 months of patients without seeding. Conclusions: The results showed no seeding in BC patients. Seeding rate after biopsy in CRC patients is not negligible, however, without affecting outcome.

Rationale and Objectives. Radiofrequency (RF) tissue ablation with a cooled needle electrode (probe) can produce large lesions. By using this technique on ex vivo calf livers, the authors evaluated the role of ultrasound (US), dose response, and temperature course with time. Methods. RF ablation was produced with a 14-gauge probe with a 2-cm exposed tip. The lesions were examined with US and macroscopically after various treatment durations. Tissue temperature was measured with thermosensors inserted 1, 2, and 3 cm from the probe. Results. Before treatment the tip of the probe was easy to visualize with US, but during treatment microbubbles obscured the lesion and probe. After treatment, the lesions appeared hypoechoic. Lesion size was underestimated based on US findings. Lesion size was logarithmically correlated to treatment duration. Lesion temperature increased at an increased rate with higher wattage applied and with decreased distance from the probe. Conclusion. US is useful for probe placement before treatment and might be of value after treatment. Lesion size increases reproducibly with treatment duration.

Two patients with disseminated prostatic cancer underwent transrectal ultrasonographic examination. In the rectal wall, at the prostatic level, tumor infiltration was seen without obvious communication to the prostate. Biopsy demonstrated adenocarcinoma, and immunohistochemic staining for prostatic specific antigen (PSA) was positive. We recommend the application of PSA staining in biopsy specimens of unclear rectal masses.