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INTRODUCTION To describe the value of contrast-enhanced ultrasound (CEUS) for the differentiation of malignant from benign parietal pleural lesions (PPLs). MATERIALS AND METHODS From November 2005 to June 2019, 63 patients with histologically/cytologically confirmed PPLs were investigated by CEUS. On CEUS, the extent of enhancement (EE; marked or reduced/absent) and the homogeneity of enhancement (HE; homogeneous or inhomogeneous) were analyzed retrospectively. RESULTS In total, 24/63 lesions were benign, and 39/63 lesions were malignant. On CEUS, 11/24 benign and 36/39 malignant lesions showed a marked enhancement. A marked enhancement was significantly more frequently associated with malignancy compared with benign lesions (p

OBJECTIVES: This prospective study aimed to evaluate the value of B-mode lung ultrasound (LUS) for the early diagnosis of coronavirus disease 2019 (COVID-19) infection in nonhospitalized COVID-19 suspected cases in a population with a low prevalence of disease. METHODS: From April 2020 to June 2020, in an ambulatory testing center for COVID-19-suspected cases, 297 subjects were examined by LUS before a nasopharyngeal swab was taken for a reverse transcription polymerase chain reaction (RT-PCR) test. The following LUS findings were defined as pathological ultrasound findings and were analyzed: the presence of 1) pleural effusion, 2) B-lines, 3) fragmented visceral pleura, 4) consolidation, and 5) air bronchogram in the consolidation. The LUS findings were compared with the RT-PCR test results. RESULTS: The result of the RT-PCR test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was positive in 11 and negative in 286 subjects, and the prevalence of COVID-19 infection in the study participants was 3.7%. On LUS, a pathological finding could be detected in 56/297 (18.9%) study participants. The LUS revealed a sensitivity of 27.3%, a specificity of 81.5%, a positive predictive value of 5.4%, a negative predictive value of 96.7%, and a diagnostic accuracy of 79.9% for the identification of COVID-19 infection. CONCLUSIONS: For the identification of COVID-19 infection, LUS is highly sensitive to the patient spectrum and to the prevalence of the disease. Due to the low diagnostic performance in nonhospitalized COVID-19 cases in low-prevalence areas, LUS cannot be considered to be an adequate method for making a diagnosis in this group.

B-mode ultrasound (B-US) is the standard imaging modality to evaluate pleural effusion. The value of B-US for assessing the malignancy of a pleural effusion (PE) is limited. For this purpose, computed tomography (CT) and thoracoscopy are the methods of choice to evaluate an effusion. The aim of this Pictorial Essay is to demonstrate contrast-enhanced ultrasound (CEUS) as a method in addition to B-US and CT for the evaluation of PE taking into account the clinical background. The characteristic patterns of pleural pathologies, effusion morphology, and associated lung parenchymal consolidations are presented.

ZusammenfassungDie allogene hämatopoietische Stammzelltransplantation (allo-SZT) stellt eine komplexe Therapie mit vielen auch gastrointestinalen Nebenwirkungen und Komplikationen dar. Eine frühzeitige Diagnose und Behandlung von mit allo-SZT assoziierten Komplikationen ist daher von großer Bedeutung, um das Überleben dieser Patienten zu verbessern. Die Sonografie stellt eine schnell verfügbare Methode dar, die am Krankenbett durchgeführt werden kann. In den Händen eines sonografieerfahrenen Untersuchers können wichtige transplantationsbedingte Komplikationen sofort diagnostiziert oder ausgeschlossen werden. Das Ziel der Arbeit ist es, den diagnostischen und klinischen Wert von Ultraschall vor, während und nach der allo-SZT darzustellen.

Purpose To describe the clinical awareness and acceptance of ultrasound-diagnosed acute epiploic appendagitis (EA) and their importance to avoid unnecessary therapeutic and imaging measures. Patients and Methods The data were obtained of n=54 patients with acute, localized, peritonitic pain and EA diagnosed by B-mode ultrasound and contrast-enhanced ultrasound examination from November 2003 to September 2020. All examinations were performed by a German Society for Ultrasound in Medicine (DEGUM) Level III qualified examiner. Based on documentation by the treating physicians, the clinical awareness and acceptance of EA diagnosis was determined in all patients and compared between subgroups diagnosed before 2013 and from 2013 onwards. In 2013, a local educational training program regarding the diagnosis of and therapy for EA was initiated for physicians. Results In all patients, EA was sonographically diagnosed by a DEGUM level III qualified examiner. At enrollment, EA was mentioned as a suspected clinical diagnosis in n=1/54 (1.9%) patient. Furthermore, in n=39/54 (72.2%) cases, the EA was documented and accepted by the treating physicians at the time of patient discharge as the final clinical diagnosis. The clinical acceptance was significantly higher from 2013 onwards compared with before 2013 (p0.05). Conclusion In our retrospective study, we showed that awareness and acceptance of the disease EA are low. Low diagnostic acceptance of EA by the clinician leads to unnecessary therapeutic and imaging measures and is a general problem related to rare diseases in the healthcare system.

This study described the frequency of malignant synchronous focal liver lesions (FLLs) in patients with newly diagnosed non-hematologic malignant disease.From June 2013 to January 2017, 434 patients with synchronous FLLs and newly diagnosed underlying malignant disease were included in the study. The diagnosis of the FLLs was made by histology and/or contrast-enhanced imaging. The final medical report was used for analysis in the study.Of the 434 liver lesions, 258 (59.4%) were malignant and 176 (40.6%) benign. All malignant lesions were metastases. The benign liver lesions were comprised of 93 cysts (21.4%), 52 hemangiomas (12.0%), 20 focal fatty sparing (4.6%), 4 focal nodular hyperplasia (0.9%), 3 unspecified benign lesions (0.7%), 2 regenerative nodules (0.5%), 1 calcification (0.2%), and 1 adenoma (0.2%). Diseases with the highest percentage frequency of synchronous malignant FLLs were cholangiocarcinoma with 86.7%, neuroendocrine tumor with 72.7%, and pancreatic carcinoma with 72.0%. Gastric carcinoma (33.3%), breast carcinoma (44.4%), and urothelial cell carcinoma (45.5%) were the diseases with the lowest percentage frequency of synchronous malignant FLLs.In total, the frequency of malignant synchronous FLLs in newly diagnosed non-hematologic malignant disease was 59.4%. In particular, cholangiocarcinoma, neuroendocrine tumor, and pancreatic carcinoma were the diseases with the highest rate of synchronous malignant FLLs.ZIEL: Beschreibung der Häufigkeit maligner synchroner fokaler Leberläsionen (FLLs) bei Patienten mit neu diagnostizierter nichthämatologischer maligner Erkrankung.Von Juni 2013 bis Januar 2017 wurden 434 konsekutive Patienten mit synchronen FLLs und neu diagnostizierter maligner Grunderkrankung in die Studie eingeschlossen. Die Diagnose der FLLs wurde durch Histologie und/oder Kontrastmittelbildgebung gestellt. Der finale Arztbrief wurde für die Analyse in der Studie verwendet.Von den 434 Leberläsionen waren 258 (59,4%) maligne und 176 (40,6%) benigne. Alle bösartigen Läsionen waren Metastasen. Bei den gutartigen Leberläsionen handelte es sich um 93 Zysten (21,4 %), 52 Hämangiome (12,0 %), 20 fokale Fettverteilungsstörung (4,6 %), 4 fokale noduläre Hyperplasien (0,9 %), 3 nicht näher spezifizierte gutartige Läsionen (0,7 %), 2 regenerative Knötchen (0,5 %), 1 Verkalkung (0,2 %) und 1 Adenom (0,2 %). Erkrankungen mit der höchsten prozentualen Häufigkeit von synchronen malignen FLLs waren das cholangiozelluläre Karzinom mit 86,7%, der neuroendokrine Tumor mit 72,7% und das Pankreaskarzinom mit 72,0%. Magenkarzinom (33,3%), Mammakarzinom (44,4%) und Urothelzellkarzinom (45,5%) waren die Erkrankungen mit der geringsten prozentualen Häufigkeit synchroner maligner FLLs.Insgesamt betrug die absolute Häufigkeit von malignen synchronen FLLs bei neu diagnostizierten nichthämatologischen malignen Erkrankungen 59,4 %. Insbesondere cholangiozelluläre Karzinome, NETs und das Pankreaskarzinom zeigten die höchste Rate an malignen synchronen fokalen Leberläsionen.

PURPOSE This retrospective study aimed to describe the B-mode lung ultrasound (B-LUS) and contrast-enhanced ultrasound (CEUS) follow-up patterns of peripheral pulmonary lesions (PPLs) in patients with confirmed pulmonary embolism (PE). PATIENTS AND METHODS Data from 27 patients with a confirmed diagnosis of PE and PPLs over 5 mm from October 2009 to November 2018 were included retrospectively in the study. The inclusion criteria were performance of a baseline CEUS examination, a short-term B-LUS and CEUS follow-up, and a long-term B-LUS follow-up of PPLs. The homogeneity of enhancement of PPLs (homogeneous/inhomogeneous/absent) on CEUS and the presence and size of PPLs on B-LUS were evaluated. RESULTS A total of n = 25/27 (92.6%) lesions showed absent or inhomogeneous enhancement during baseline examination or short-term follow-up, indicating impaired perfusion. On short-term CEUS follow-up, 9/27 cases (33.3%) showed a pattern shift. On B-LUS long-term follow-up, 26/27 lesions (96.3%) were detectable for an average of 10 weeks (range 3-32 weeks). The size of reference lesions was significantly reduced at the time of the final follow-up examination (P

OBJECTIVES Here we asked, whether contrast enhanced ultrasound (CEUS) enables to judge early treatment response in malignant lymphoma as a potential guidance for further treatment. METHODS From May 2017 to May 2018, 21 patients with histologically confirmed diagnosis of lymphoma were examined by B-mode ultrasound (B-US) and CEUS at fixed early time points after commencing therapy (days [d] 0, 15 and 30 after therapy start) and contrast enhancement patterns in target lymphoma lesions were quantified using Bracco-VUE Box® (DCE-US). To estimate the potential value of CEUS-enhancement patterns for early response prediction, patients were grouped according to their best achieved actual response into complete remission (CR) patients, partial remission (PR) patients or progressive disease (PD) patients. RESULTS Between d0, d15 and d30, CR-patients showed a median lymphoma shrinking by 34% in B-US. PD-patients experienced a median lymphoma size reduction by 44% on day 15, but lymphoma mass again increased by 20% between d15 and d30. In contrast, the median CEUS enhancement intensity, as assessed by the area under the curve (AUC) was increasing at d15 in CR and PD patients (CR to 152%, PD: to 126%), but decreased at d30 to 14% in CR patients and 22% in PD patients. CONCLUSIONS While early response assessment using B-US might be useful to predict treatment response in lymphoma, CEUS and DCE-US-although often feasible-do not provide additional value in this regard.

OBJECTIVE The purpose of this case series is to evaluate the diagnostic potential of contrast-enhanced ultrasound (CEUS) in patients with clinically suspected pulmonary embolism (PE), suspicious pleural lesions, and negative computed tomography pulmonary angiogram (CTPA). PATIENTS/METHODS Between January 2017 and January 2018, we examined patients with an intermediate or a high-risk Wells score and a negative CTPA with lung B-mode ultrasound (LUS). In a total of six patients, pleural defects were identified and further examined by CEUS. Nonenhancing lesions or those with inhomogeneous enhancement were considered to be suspicious for an embolic event and biopsied for histological validation. The data analysis was retrospective. RESULTS In LUS, the lesions had an average size of 2.4 cm (range 2-3 cm). Five were hypoechoic and one was complex. The shape was wedge shaped (n = 5) or round (n = 1), and the number was solitary (n = 4) or multiple (n = 2) with dorsobasal localization (n = 6). Three lesions were nonenhancing, and three had an inhomogeneous enhancement with areas with complete absence of enhancement. The histological examination showed pulmonary infarction in all six cases, and in one patient also cells of a lung carcinoma. CONCLUSION Our case series demonstrates the diagnostic potential of CEUS for detecting peripheral pulmonary infarction in patients with clinically suspected PE and negative CTPA scan regarding PE. A histological validation or a narrow follow-up might be warranted in some cases.

PURPOSE: To describe perfusion patterns of peripheral pulmonary lesions (PPLs) in COVID-19 patients using contrast-enhanced ultrasound (CEUS). PATIENTS AND METHODS: From April 2020 until July 2020, 11 consecutive patients with RT-PCR-confirmed COVID-19 and PPLs sized over 5 mm were investigated by B-mode ultrasound (B-US) and CEUS. The homogeneity of enhancement (homogeneous and inhomogeneous) was examined retrospectively using CEUS. An inhomogeneous enhancement was defined as a perfused lesion with coexisting non-perfused areas (NPA). RESULTS: On B-US, all 11 patients showed an interstitial syndrome (B-lines) with PPLs between 0.5 and 6 cm. On CEUS, all cases showed peripheral NPA during the complete CEUS examination. One patient underwent a partial lung resection with subsequent histopathological examination. The histological examination showed vasculitis, microthrombus in the alveolar capillary, and small obliterated vessels. CONCLUSION: In our case series, PPLs in patients with RT-PCR-confirmed COVID-19 infection presented a CEUS pattern with NPA during the complete CEUS examination. Our findings suggest a peripheral pulmonary perfusion disturbance in patients with COVID-19 infection. In 1 case, the histopathological correlation with the perfusion disturbance in the PPL was proven.

The evaluation of lymph nodes (LNs) using ultrasound requires a high level of clinical and sonographic competence. This “pictorial essay” is intended to illustrate eye-catching examples of relevant “clinical-sonographic visual diagnoses” of LNs. We provide typical images and take-home messages of eye-catching features to illustrate the featured publications.The first part includes “important differential diagnoses of eye-catching features of suspected lymphadenopathy” and “benign lymphadenopathy”. The second part will include “Eye-catching features of malignant lymphadenopathy, both carcinoma and lymphoma”

Objectives To determine contrast enhancing features of mediastinal masses (ML) using transcutaneous contrast-enhanced ultrasound (CEUS). Methods Retrospective analysis of n = 58 patients with histologically confirmed ML, which were examined in the period from October 2005 to February 2018 using transcutaneous B-mode ultrasound and CEUS. In n = 29 (50%) histological confirmation was performed by ultrasound guided core-needle biopsy. The lesions were evaluated using CEUS in regard to the enhancement pattern (hyper-, iso-, hypoenhancement, non-enhancement, homogenous, inhomogenous) compared to enhancement of the spleen as an in vivo reference. Results N = 53 (91.4%) of ML were malignant (m) (lymphoma n = 36, metastasis n = 11, thymoma n = 2, teratoma n = 1, sarcoma n = 2, seminoma n = 1). In n = 5 (8.6%) cases there was a benign (b) histology (thyroid tissue n = 2, thymus residue n = 1, ganglioneurinoma n = 1, scar tissue: n = 1). In ultrasound, n = 53 (91.4%; (48 = m, 5 = b)) were hypoechoic, n = 5 (8.6%, (5 = m,0 = b)) hyperechoic. In CEUS, n = 35 lesions presented an arterial isoenhancement (60.3%; 33 = m, 2 = b). An arterial hypoenhancement had n = 21 (36.2%, (20 = m,1 = b)), and no enhancement showed n = 2 (3.5%, (0 = m, 2 = b) of the ML. A parenchymal isoenhancement was observed in n = 1 (1.7%, (1 = m, 0 = b)), a hypoenhancement in n = 54 (93.1%; 51 = m, 3 = b) of the patients and almost no enhancement in n = 3 ML (5.2%, (1 = m, 2 = b).) The enhancement was homogeneous in n = 26 (44.8%, (25 = m,1 = b)) cases, in n = 31 (53.5%, (28 = m,3 = b)) inhomogeneous and n = 1 (1.7%) benign lesion was exclusively cystic. Conclusion In CEUS, mediastinal tumor formations showed variable arterial enhancement, followed by parenchymal hypoenhancement (wash-out).

Purpose: In contrast to splenomegaly, the clinical value of a small spleen (hyposplenia) is unclear. Contrast-enhanced ultrasound (CEUS) has not been investigated systematically in hyposplenia. Methods: Between February 2005 and January 2017, 43 patients with hyposplenia (< 7 × 3 cm) were examined by B-mode ultrasound (US) and CEUS. A retrospective data analysis was performed. Results: A total of 39 (91%) patients had an underlying disease (UD; allogenic stem cell transplantation, n = 16; autoimmune-diseases, n = 7; sickle cell anemia, n = 5; solid tumors, n = 5; others, n = 6). In 4 (9%) cases, hyposplenia was an incidental finding. The echogenicity of the spleen was normal (homogeneous, isoechogenic) in 17 (39.5%) and abnormal in 26 (60.5%) cases (inhomogeneous, n = 26 and hyperechoic, n = 9). In CEUS, 21 (49%) patients presented a normal isoenhancement. An abnormal enhancement was detected in 22 (51%) patients with UD (arterial/parenchymal inhomogeneous, n = 1; no [arterial, n = 3 and parenchymal, n = 6]; reduced [arterial, n = 8 and parenchymal, n = 15]). Conclusions: Hyposplenia is a rare pathologic finding and often associated with hematological/oncological and autoimmune diseases. Furthermore, altered B-mode US appearance and a pathological CEUS pattern are frequently found. However, the clinical implication, especially regarding splenic function remains obscure to date.

Here, we describe the appearance and pattern of pulmonary lymphoma on B-mode imaging and with contrast-enhanced ultrasound (CEUS). From July 2009 to December 2015, 6 patients with histologically or cytologically confirmed lymphoma of the lung were examined by B-mode imaging, followed by CEUS. A retrospective analysis of the imaging data was performed with respect to the time to enhancement, pulmonary artery (PA) and bronchial artery, echogenicity (hypoechoic, isoechoic, or hyperechoic), and homogeneity (homogeneous or inhomogeneous) of the contrast enhancement. On B-mode imaging, all 6 pulmonary lymphoma lesions were hypoechoic. Five cases had PA enhancement, and 1 case had bronchial artery enhancement on CEUS imaging. Strikingly, all 6 patients had isoechoic arterial contrast enhancement. In the parenchymal phase, 3 of the lymphoma lesions showed hypoechoic contrast enhancement, and 3 showed isoechoic enhancement. Pulmonary lymphomas are hypoechoic on B-mode imaging. With CEUS, all patients had predominant PA contrast enhancement in the arterial phase with variable parenchymal contrast enhancement. Thus, definite differentiation from other malignant or benign pulmonary lesions cannot be achieved by CEUS.

Detection of mesenteric masses (MM) by 2 D ultrasound often causes a diagnostic dilemma, and histological confirmation is required for definite diagnosis. The value of contrast-enhanced ultrasound (CEUS) for the diagnosis of MMs has not been investigated before. Here, we retrospectively evaluate 2D-mode and CEUS patterns of 69 patients with histologically confirmed MMs. Between January 2006 and January 2016, n = 69 patients were included in the study. Histopathological data, clinical data, 2D-mode ultrasound and CEUS enhancement were retrospectively analyzed. More than half of the MMs (n = 47/69, 68 %) revealed a malignant histology. The size of the MM, inflammation markers and clinical symptoms did not correlate with the histological outcome. 2 D mode revealed n = 46 (67 %) lesions as hypoechoic, n = 14 (20 %) as hyperechoic, and n = 9 (13 %) with a complex echo pattern. Hypoechogenicity and complex echo patterns as well as regular borders of MMs were significantly associated with malignancy (p 0.05). On CEUS, malignant MMs showed arterial hyperenhancement (n = 11/47, 23 %), isoenhancement (n = 25/47, 52 %) and hypoenhancement (n = 7/47, 15 %). The majority of malignant MMs (n = 42/47, 89 %) revealed parenchymal hypoenhancement. Benign masses revealed arterial hyperenhancement in n = 1/22 (5 %), isoenhancement in n = 8/22 (36 %), and hypoenhancement in n = 10/22 (45 %). The majority of lesions showed parenchymal hypoenhancement (n = 19/22, 86 %). Hypoechogenicity and complex echogenicity in 2 D mode, irregular borders, and parenchymal wash-out were more often associated with malignancy. However, CEUS did not help to subclassify malignant MMs according to their histological entity.ZIEL: Der Stellenwert der kontrastunterstützten Sonografie (KUS) zur Beurteilung von mesenterialen Raumforderungen (mRF) ist bisher nicht systematisch untersucht worden. In dieser Arbeit werden 69 Patienten mittels B-Bild Sonografie und KUS retrospektiv analysiert. Die histopathologischen Befunde, klinische Daten, B-Bild- und KUS Daten von n = 69 Patienten mit mRF wurden über den Zeitraum von 10 Jahren (Januar 2006-Januar 2016) ausgewertet. Maligne mRF wurden in n = 47/69 (68 %) gefunden. Weder die Größe, Laborwerte, noch die klinische Symptomatik korrelierte mit der Dignität. In der B-Bild Sonografie zeigten sich n = 46 (67 %) mRF echoarm, n = 14 (20 %) echoreich und n = 9 (13 %) mit einem komplexen Echomuster. Echoarmes und komplexes Echomuster, als auch scharfe Begrenzung der mRF waren signifikant häufiger mit Malignität assoziiert (p 005). In der KUS zeigten maligne mRF ein arterielles Hyperenhancement (n = 11/47, 24 %), ein Isoenhancement (n = 25/47, 52 %) und ein Hypoenhancement (n = 7/47, 15 %). Ein Großteil der malignen mRF waren durch ein parenchymales Hypoenhancement gekennzeichnet (n = 42/47, 89 %). Gutartige mRF zeigten ein Hyperenhancement in n = 1/22 (5 %), ein Isoenhancement in n = 8/22 (36 %) und ein Hypoenhancement in n = 10/22 (45 %). Die Mehrzahl der benignen mRF wiesen ein parenchymales Hypoenhancement (n = 19/22, 86 %) auf. Echoarme und komplexe mRF, scharfe Begrenzung und parenchymales wash out sind signifikant häufiger mit Malignität assoziiert. Die KUS scheint jedoch keine Subklassifizierung der histologischen Entitäten zu erlauben.

Objectives Whole surgical lymph node excision (SNE) is considered the standard diagnostic method in the primary diagnosis of lymphadenopathy (LA) suspected of malignancy. Ultrasound-guided full core needle biopsy (UFCNB) offers an alternative method to SNE. This study examined the accuracy of UFCNB in the diagnosis of unexplained LA in 793 cases. Methods From January 2006 to June 2015, a total of 793 cases of LA of unknown origin received a UFCNB. The lymph nodes were located peripherally (68%) or abdominally (32%). The final diagnoses from histopathologic examinations were non-Hodgkin lymphoma (n = 245), Hodgkin lymphoma (n = 53), solid nonlymphocytic lymph node metastases (n = 359), and benign LA (n = 136). The results of the biopsies were retrospectively evaluated with regard to sensitivity, specificity, and diagnostic accuracy. Results In the total collective of 793 biopsies, the sensitivity of UFCNB was 94.4%; the specificity was 97.8%; and the diagnostic accuracy was 95.0%. In the subgroups, the following results were obtained: non-Hodgkin lymphoma (sensitivity, 97.2%), Hodgkin lymphoma (sensitivity, 88.7%), metastases (sensitivity, 93.3%), and benign LA (specificity, 97.8%). In 17 cases (2.2%), an additional rebiopsy of the lymph node was needed, and in 85 cases (10.7%), an additional SNE was performed. Conclusions Due to the diagnostic accuracy of 95.0% in the total collective, UFCNB seems to be an alternative diagnostic procedure to the standard procedure of SNE for LA of unknown origin. A prospective comparative study to definitively clarify the diagnostic value of UFCNB compared to SNE in the unexplained LA is warranted.

The evaluation of lymph nodes (LN) using ultrasound requires a high level of clinical and sonographic competence. This “pictorial essay” is intended to illustrate eye-catching examples of relevant “clinical-sonographic visual diagnoses” of LNs. We provide typical images and take home messages of eye-catching features to illustrate the featured publications.The first part included the introduction into the subject, indications for US examination and the widely accepted recognized features for LN characterization. The key features for the differential diagnosis of suspected lymphadenopathy and benign lymphadenopathy are illustrated. In the second part eye-catching features of malignant lymphadenopathy and the differential diagnosis of carcinoma and lymphoma are shown

To describe the vascularization of peripheral lung carcinoma in CEUS and to compare with B-mode ultrasound (US) and clinical data. From April 2004 until September 2015, n = 89 patients with peripheral lung carcinoma were investigated by B-mode US and CEUS. The extent (EE: hypoechoic, hyperechoic), homogeneity (HE: homogeneous, inhomogeneous) and time of enhancement (TE) have been defined. Early pulmonary-arterial enhancement (PA) before contrast floating to the thoracic wall was differentiated from simultaneous or delayed bronchial-arterial enhancement (BA). CEUS parameters were compared by B-mode US and histology. n = 25 patients had early PA enhancement (TE: 8 ± 3.7 s), and n = 64 (72 %) had simultaneous/delayed BA enhancement (TE: 17.6 ± 6.2 s) (p 0.001). PA enhancement (EE/HE) was hyperechoic (n = 11/25), homogeneous (n = 11/25) and showed an air bronchogram more often (n = 11/17, p 0.001). BA enhancement (EE/HE) was frequently hypoechoic (n = 34/64) and inhomogeneous (n = 54/64). BA enhancement was associated with necrosis (n = 36/42, p = 0.009). PA and BA enhancement distributed to different histologies: n = 42 adenocarcinomas (18 PA, 24 BA), n = 30 squamous cell carcinomas (4 PA, 26 BA), n = 13 other types of NSCLC (3 PA, 10 BA), and n = 4 SCLC (0 PA, 4 BA) (p = 0.016). The vascularization of peripheral lung carcinomas is heterogeneous and is influenced by histology. In this study, lung carcinomas are predominantly supplied by bronchial arteries, whereas a part of adenocarcinomas and non-adenocarcinomas show PA enhancement.ZIEL: Beschreibung von B-Bild-Ultraschall (US) und CEUS-Mustern peripherer Lungenkarzinome mittels CEUS in Bezug zu Histologie und klinischen Parametern. Im Zeitraum von April 2004 bis September 2015 wurden n = 89 Patienten mit histologisch gesichertem peripherem Lungenkarzinom im B-Bild-US und CEUS untersucht. In der CEUS wurden Ausmaß (EE: hypoechogen, hyperechogen), Homogenität (HE: homogen, inhomogen) und die Zeit zum Enhancement (TE) bestimmt. Ein vorzeitiges pulmonal-arterielles Enhancement (PA) wurde im Vergleich zur Thoraxwand von einem zeitgleichen bronchial-arteriellen Enhancement (BA) unterschieden. CEUS-Daten wurden mit B-Bild-US und Histologie verglichen. n = 25 Patienten (28 %) hatten ein vorzeitiges PA-Enhancement (TE: 8 ± 3,7 s), n = 64 (72 %) ein zeitgleiches BA-Enhancement (TE: 17,6 ± 6,2 s) (p 0,001). Das PA-Enhancement (EE/HE) war hyperechogen (n = 11/25), homogen (n = 11/25) und zeigte im B-Bild-US häufiger ein Aerobronchogramm (n = 11/17, p 0,001). Das BA-Enhancement (EE/HE) war bevorzugt hypoechogen (n = 34/64) und inhomogen (n = 54/64). Bei einem BA-Enhancement fanden sich häufiger Nekrosen (n = 36/42, p = 0,009). PA- und BA-Enhancement verteilten sich in den unterschiedlichen Histologien: n = 42 Adenokarzinome (18 PA, 24 BA), n = 30 Plattenepithelkarzinome (4 PA, 26 BA), n = 13 sonstige NSCLC (3 PA, 10 BA) und n = 4 SCLC (0 PA, 4 BA) (p = 0,016). Die Vaskularisation von peripheren Lungenkarzinomen ist heterogen und wird durch die Histologie beeinflusst. Es zeigt sich neben einer vorherrschend bronchial-arteriellen Versorgung von malignen Lungentumoren auch ein Anteil von Adenokarzinomen und Nicht-Adenokarzinomen, die ein PA-Enhancement aufweisen.

Value of contrast-enhanced-ultrasound (CEUS) in the evaluation of residual lesions (RL) after therapy in patients with malignant lymphomas (ML) and testicular cancer (TC) with regard to tumor activity. From May 2004-October 2010, in n = 52 patients with ML (n = 34) or TC (n = 18) and RL, B-mode-imaging and CEUS of the RL was performed. In CEUS, differentiation was made between high-enhancement (HE), low-(LE) or no-enhancement (NE) of the RL after therapy. Data were retrospectively evaluated. A positive test result (HE) was found in n = 13 (25%); a negative test result (LE/NE) in n = 39 (75%) patients. Sensitivity was 72.7%, specificity 87.8%, positive likelihood-ratio 5.96, negative likelihood-ratio 0.31. In the subgroup of ML a sensitivity of 80% and a specificity of 86.2% was reached. Active residual disease in ML and TC is associated with a marked enhancement, so CEUS might be helpful in the evaluation of RL, especially to exclude residual disease.

Purpose To analyze and describe the contrast-enhanced ultrasound (CEUS) patterns of peripheral lung lesions in patients with pulmonary embolism (PE) confirmed on CT angiography or lung scintigraphy. Methods CEUS had been performed on 35 patients with peripheral lung lesions detected on gray-scale imaging and confirmed as PE. The following data were evaluated retrospectively: (1) accumulation of contrast medium (absent or present), (2) differentiation between pulmonary arterial (PA) and bronchial arterial blood supply, and (3) contrast-enhancement pattern (absent/nonhomogeneous or homogeneous). A CEUS pattern of absent or nonhomogeneous enhancement was suspicious (ie, typical) of embolic consolidations (EC), whereas a pattern of homogeneous PA enhancement was considered to be atypical of EC. Results Peripheral lesions showed a CEUS pattern suspicious of EC in 80% of the patients, with no enhancement in 40% and nonhomogeneous enhancement in another 40%. A CEUS pattern of homogeneous PA enhancement, atypical of EC, was identified in the remaining 20% of the patients. Pulmonary lesions larger than 1 cm showed vascularization more often than smaller lesions did (p < 0.001). Conclusions Peripheral lung lesions in patients with confirmed PE show a CEUS pattern of absent or nonhomogeneous contrast enhancement for suspicious EC. Further prospective studies are required to verify the diagnostic accuracy of CEUS for EC. © 2015 Wiley Periodicals, Inc. J Clin Ultrasound, 2015

Ultrasonography of the hip has gained wide acceptance as reliable method for diagnosing developmental hip dysplasia in infants. This blinded study was conducted to investigate the influence of two linear probes with different frequency on diagnostic accuracy and reproducibility. In 206 consecutive newborns, the bony roof angle (α-angle) and cartilage roof angle (β-angle) were assessed by three investigators according to Graf. The hips were measured twice both with a 7.5 MHz and a 12 MHz linear transducer (Sonoline G60S ® ultrasound system; Siemens, Erlangen, Germany). Each investigator evaluated his sonograms 6 weeks later. Depending on the mean values for α-angle and β-angle, the hips were classified. Reproducibility of the Graf classification was not found to be influenced. In two of three investigators, we observed significant improvement concerning variation of the β-angle with the 12 MHz probe. The use of high-resolution transmitters may improve diagnostic accuracy in ultrasonography of the newborn’s hip.

Purpose: Veno-occlusive disease (VOD) is a severe complication of allogenic stem cell transplantation (allo-SCT). The diagnosis of VOD is often difficult and relies on clinical assessment and clinical chemistry. B-mode ultrasound (B-US) and color doppler sonography (CDS) are only of limited additional diagnostic value. We recently observed a patient with VOD, who revealed a pathologic hepatic CEUS pattern (reduced portal venous and parenchymal enhancement). Because CEUS is a measure of perfusion, this suggested that CEUS could potentially be a novel diagnostic tool of VOD (Trenker et al. Bone Marrow Transplantation, 2018). The aim of the present study was to prospectively analyze the hepatic CEUS pattern prior and post allo-SCT and correlate these results with the pre allo-SCT VOD-risk-score, clinical findings suggestive of VOD, as well as with standard B-US and CDS findings. Patient/ Material/ Methods: From April to July 2018 13 consecutive patients, who underwent allo-SCT (n=6 AML, n=5 ALL, n=1 MDS, n=1 NHL) and had at least one VOD risk factor (Bu/Cy therapy, TBI, mismatched/haplo donor, prior liver damage, re-allo-SCT) were included. All patients received VOD prophylaxes with 300 IU unfractionated heparin /h. Elevated transaminases, bilirubin, g-GT, ascites, hepatomegaly, splenomegaly, reduced portal flow, weight gain >5 KG, as well as abdominal pain were considered as clinical signs of VOD and assessed prior and during allo-SCT. B-US and CEUS were performed at defined times before and after allo-SCT (day (d) +10 and at leucocyte engraftment (LE). The one-minute hepatic enhancement (OMHE) in CEUS (Fig. 1A, 1B) was standardized to splenic enhancement as in vivo reference by two independent investigators and retrospectively quantitated using optical density (OD) measurements software (QuantityOne) (Fig. 1C). A hypo-OMHE in CEUS was arbitrarily defined as pathological (PE), if the optical density of the liver was less than 90% compared to mean optical density of the spleen. Results: Eight of 13 (61.5%) patients had a pathological OMHE in CEUS (1 patient only prior-, 1 patient prior and post, and 6 only post-allo-SCT), suggestive of malperfusion. The median optical density in the pathological OMHE-group was 56.46% (range 34.5-81.4) and thus significantly lower than in the non- pathological group (105.6%, range 90.2-125.9) (p Conclusion: Patients undergoing allo-SCT frequently show a pathological hepatic CEUS pattern, which can be quantified by OD measurement and is suggestive of preclinical VOD or yet undefined hepatic pathologies. Further studies to evaluate the clinical significance of a PE with regard to VOD development and risk of GvHD are ongoing. Figure 1. Figure 1. Disclosures Burchert: Pfizer: Honoraria; Bayer: Research Funding; Bristol Myers Squibb: Honoraria, Research Funding; AOP Orphan: Honoraria, Research Funding; Novartis: Research Funding. Görg:Bracco imaging: Other: Bracco imaging supports workshop for contrast enhanced ultrasound for education at the university hospital in Marburg.

PURPOSE B-mode ultrasound (US) of hepatic candidiasis (HC) shows an uncharacteristic pattern. The aim of this study is to display the pattern of HC by performing contrast-enhanced ultrasound (CEUS). PATIENTS AND METHODS Between May 2006 and June 2008 HC was diagnosed in 12 patients (4 female, 8 male) by clinical and sonographic findings. The underlying diseases were acute leukemia (n = 10), aplastic anemia (n = 1), and testicular cancer (n = 1) in either the state of complete remission (n = 10) or relapse (n = 2). Due to neutropenic fever after chemotherapy all of the patients had received antifungal therapy. When HC was diagnosed all patients were afebrile and in a recovered hematological constitution. Additional diagnostic procedures were histological examination (n = 5), computed tomography (n = 8) and sonographic follow-up examinations (n = 12). All patients were examined with B-mode US and CEUS. RESULTS In B-mode US the lesions were hypoechoic (n = 12), multiple (n = 10) and > 1 cm (n = 8) as well as > 2 cm (n = 4) in diameter. During CEUS no enhancement of contrast media in the centre of the lesions was seen in all cases during both phases. Additionally, in the arterial phase, the lesions showed no rim enhancement (n = 3) (type I), an isoechoic rim enhancement (n = 5) (type II), or a hyperechoic rim enhancement (n = 4) (type III). During sonographic follow-up a complete regression of the lesions (n = 9) or a stable disease (n = 2) was seen. One patient died due to a relapse. CONCLUSION The CEUS pattern of HC is variable but characteristic. Therefore, CEUS should be performed in all patients with suspected HC.

The incidentally found primary intrasplenic tumor is mostly benign, but leads to a well known clinical problem: B-mode sonography, as well as computed tomography and MRI are often non-specific, and it is unclear whether a histological verification is warranted or a sonographic follow-up is justified.etween October 2003 and October 2007 40 consecutive patients showed an echoic primary tumor of the spleen incidentally found by B-mode ultrasound (US) and were included in this prospective study. All tumors were classified regarding size and echogenity. In all patients contrast-enhanced ultrasound (CEUS) was perfomed and tumor enhancement was characterized in comparison to normal splenic enhancement. Patients were followed up every 3 months during the first year, and then once a year.Sizes of the lesions were3 cm in diameter in 28 (70 %), between 3 - 5 cm in 10 (25 %) and5 cm in 2 (5 %) patients. Lesions were classified as predominantly hypoechoic (n = 27) and hyperechoic (n = 13) on B-mode US. During the arterial phase the lesions showed a hyperechoic (n = 12), isoechoic (n = 8), hypoechoic (n = 14), and anechoic (n = 6) enhancement on CEUS. Median follow was 24.8 months (range 3 - 48 months). Lesions were constant in size (n = 34) or shrinking (n = 5). In one patient a new 5 mm lesion was seen during follow-up. This patient refused the splenectomy and follow-up was continued without further tumor growth.Echoic splenic tumors incidentally found by ultrasound can be managed by sonographic follow-up examinations.

The somatic V617F mutation in the Janus kinase (JAK) 2 gene, which causes a valine to phenylalanine substitution at position 617, has recently been found in the majority of patients with polycythemia vera and in many cases with essential thrombocythemia or idiopathic myelofibrosis. Here, we report on a 76-year-old female patient presenting with JAK2V617F-positive polycythemia vera and a pelvic mass with extramedullary hematopoiesis. Immunohistochemistry demonstrated tyrosine phosphorylation of JAK2 kinase as well as STAT1 and STAT5 transcription factors. However, only a minority of the total STAT1 pool was tyrosine-phosphorylated and, in contrast to its unphosphorylated counterpart, phospho-STAT1 clearly showed nuclear accumulation. While megakaryotes expressed virtually no phospho-STAT1, phosphorylated STAT5 was mainly restricted to megakaryocytes and rarely detected in non-megakaryocytes. Our data suggest that dysregulated STAT signal pathways are engaged in extramedullary hematopoiesis in polycythemia vera.

Ziel: Darstellung kontrastmittelsonografischer Befunde von Patienten mit Appendizitis epiploica (AE). Patienten und Methoden: Zwischen Mai 2005 und Dezember 2007 wurde bei 15 Patienten die Diagnose einer AE anhand klinischer und B-Bild-sonografischer Befunde gestellt. 13 Patienten waren mannlich, 2 weiblich. Das Alter variiert zwischen 11 und 78 Jahren. Alle Patienten wurden mit einer kontrastunterstutzten Sonografie (KUS) untersucht. Das Ausmas der Kontrastmittelanreicherung in der Lasion wurde klassifiziert im Vergleich zum umgebenden Fettgewebe als In-vivo-Referenz (fehlende, hyperechogene, gemischte Kontrastaufnahme). Eine B-Bild-sonografische Verlaufskontrolle erfolgte bei allen Patienten. Zusatzliche diagnostische Prozeduren waren Computertomografie (n = 8), Kolonoskopie (n = 5) und Operation (n = 1). Ergebnisse: In der KUS zeigten alle Lasionen eine zentral fehlende Kontrastaufnahme, wobei zwischen einer gemischten Kontrastaufnahme (n = 11) oder fehlenden (n = 4) unterschieden wurde. In Fallen mit gemischter Aufnahme zeigte sich ein kleines zentrales Areal mit fehlender Kontrastierung sowie einer breiten perilasionalen verstarkten Kontrastmittelaufnahme (> 1 mm). In Fallen mit fehlender Kontrastaufnahme war um das zentrale nicht kontrastaufnehmende Areal lediglich ein schmaler hyperechoger Randsaum nachweisbar (≤ 1 mm). Schlussfolgerung: Die Diagnose einer AE ist durch Klinik, fehlendes Entzundungslabor und B-Bild-sonografisches Bild zu stellen. Die AE hat ein charakteristisches Befallsmuster in der KUS. Die KUS kann somit in unklaren Fallen hilfreich zur Diagnosesicherung einer AE sein. Purpose: To present our experience with contrast-enhanced ultrasound (CEUS) in patients with epiploic appendagitis (EA). Patients and Methods: From May 2005 to December 2007, 15 patients with the clinical and B-mode sonographic diagnosis of EA (13 men and 2 women, aged 11 – 78 years) were included in the study. All patients were examined by CEUS. The extent of contrast enhancement of the fatty tissue masses was measured using the normal surrounding fat tissue enhancement as an in vivo reference (no, hyperechoic, mixed enhancement). B-mode sonographic follow-up examinations were performed in all cases. As additional diagnostic procedures, computed tomography (n = 8), colonoscopy (n = 5), and surgery (n = 1) were used. Results: With CEUS all 15 masses showed a central area of no enhancement. Masses with a central unenhanced area and with broad perilesional enhancement (> 1 mm) were classified as mixed enhancement (n = 11). In the 4 cases classified as no enhancement the central unenhanced area was demarcated by only a marginal hyperechoic rim (≤ 1 mm). Conclusion: EA is diagnosed by clinical, laboratory and B-mode sonographic patterns. EA shows a fairly characteristic CEUS feature. CEUS may therefore be helpful to confirm the diagnosis of EA in equivocal cases.

Abdominal sonography is now the most frequently used screening method for the detection of abdominal lymph node enlargement. For proper classification, size, localisation and infiltration pattern must be known. The definitive determination whether lymph nodes are benign or malignant cannot be made by the size of the lesion alone. The localisation (parietal/visceral) of enlarged lymph nodes has been shown to be of significance in the staging of abdominal carcinomas. Different infiltration patterns (diffuse small nodular, focal small nodular, focal large nodular, bulky formations) show the broad spectrum of abdominal lymphomas detected by ultrasound. Knowledge of these different infiltration patterns together with clinical information often helps to discriminate between lymph node enlargement caused by inflammation, metastasis, or malignant lymphoma. The definitive diagnosis is made via laparotomy, ultrasound guided biopsy or sonographic follow-up studies.

Report on twelve patients suffering from malignant primary disease associated with pleural effusion and diaphragmatic metastasis, basically diagnosed via sonography. In no case tumour formation could be detected by x-ray film. Cytohistological evidence of diaphragmal metastasis can be found by sonographically detected pleural tumours malignant effusion must be assumed, despite negative exudate cytology. In such cases diagnostic thoracoscopy is not necessary.

Objective Transcutaneous ultrasound enables visualization of pleural-based lesions but with a poor correlation to specific pathology. Ultrasound contrast agents in conjunction with contrast-specific imaging techniques are increasingly accepted in clinical use. Based on the dual arterial supply of the lung, this organ is suited for evaluation of arterial vascularity by contrast-enhanced sonography (CES). This review will present first data about practise and clinical use of CES in patient with peripheral lung lesions. Methods This review is based on the experience of transcutaneous CES in 350 patients with chest pathology diagnosed by B-mode sonography at an internal medicine center. CES studies were performed with a contrast-devoted unit (Acuson, Sequoia, Siemens medical solution) that had contrast-specific, continuous-mode software. A low mechanical index was used. A sulfur hexafluoride-based microbubble contrast medium (Sonovue ® , Bracco SpA, Milan, Italy) was injected. Pulmonary lesions were characterized by CES regarding time to enhancement (TE) and extend of enhancement (EE). Results CES in peripheral lung lesions is feasible and depending on underlying diseases lesions may show a variable TE and EE. CES enables to distinguish pulmonary arterial supply from bronchial arterial supply by TE. First experiences with CES have shown that various peripheral lung lesions do have a characteristic CES pattern regarding TE and EE. First clinical data show that there are clinical conditions, which may show a diagnostic advantage of CES in comparison to B-mode US. CES may be helpful (1) to confirm diagnosis of pleurisy, (2) to confirm diagnosis peripheral pulmonary embolism, (3) to characterize lung opafication to atelectasis, pneumonia, and tumor, and (4) to assist in interventional procedures. Conclusion : CES of the chest is limited to pleural-based lesions. CES enables to characterize lung lesions regarding TE and EE. The clinical benefit is yet unclear, but first results are encouraging.

Objective Ultrasound contrast agents in conjunction with contrast specific imaging techniques, are increasingly accepted in clinical use for diagnostic imaging in several organs. Contrast enhanced sonography (CES) of second-generation contrast media have shown a spleen-specific uptake of the microbubble contrast agent. The aim of this review is to illustrate indications for the use of CES in patients with suspected (peri-)splenic pathology. Methods This review based on the experience of transcutaneous CES in 200 patients with (peri-)splenic pathology diagnosed by B-mode sonography at an internal medicine center. CES studies were performed with a contrast-devoted unit (Acuson, Sequoia, Siemens medical solution) that had contrast-specific, continuous-mode software. A low mechanical index was used. A sulfur hexafluoride-based microbubble contrast medium (Sonovue®, Bracco SpA, Milan, Italy) was injected. Results On our experience, there are several clinical conditions which may show an diagnostic advantage of CES in comparison to B-mode US. CES should be performed to investigate: (1) the perisplenic tumor to diagnose or exclude accessory spleen, (2) the small-sized spleen to diagnose functional asplenia/hyposplenia, (3) the inhomogenous spleen of unknown cause to diagnose focal lesions within the spleen, (4) the incidentally found hypoechoic splenic tumor to diagnose high vascular splenic hemangioma, (5) focal lesions suspect for splenic abscess, hematoma, infarction to confirme diagnosis, and (6) patients with abdominal trauma to diagnose or exclude splenic injuriy. Conclusion CES is of diagnostic value in several clinical circumstances to diagnose accessory spleen, functional asplenia, small-sized splenic involvement, high vascular splenic hemangioma, and vascular splenic pathology like splenic infarction, splenic abscess, and splenic laceration.

Purpose Transcutaneous ultrasound enables visualization of pleural based lesions but with a poor correlation to specific pathology. Ultrasound contrast agents in conjunction with contrast specific imaging techniques are increasingly accepted in clinical use. Up to date there are no data about the use of contrast enhanced sonography (CES) in a large series of pleural based pulmonary lesions. Materials and methods From August 2004 to August 2005, 137 consecutive patients with pleural based pulmonary lesions on B-mode sonography were studied by CES using a transcapillary second-generation contrast agent (SonoVue(R)). The following CES parameters were retrospectively evaluated. Time to enhancement (TE) of contrast agent after i. v. application was determined and classified as short TE ( 6 sec). Extent of enhancement (EE) was evaluated during the arterial phase (2 - 30 sec) and the parenchymal phase (1 - 5 minutes) by using the normal splenic tissue as an in vivo reference, and classified in reduced EE (anechoic/hypoechoic) vs. marked EE (isoechoic/hyperechoic) during both phases. Homogeneity of enhancement (HE) was classified as homogeneous vs. inhomogeneous. 60 patients had histologically confirmed malignant lesions due to central lung cancer (n = 31), and peripheral malignant lesions (n = 29). 77 patients had benign pleural based lesions including pneumonia (n = 32), pulmonary embolism (n = 20), compression atelectasis (17), and other benign pleural based lesions (n = 8). Results Malignant and benign lesions did not vary significantly regarding TE, EE, and HE. However, there were highly significant differences in the ratio of short vs. delayed TE and reduced vs. marked EE between the six disease groups. Characteristic patterns were short TE with marked EE in all compression atelectasis cases and in 62 % of patients with pneumonia. Delayed TE and reduced EE was seen in all patients with pulmonary embolism and in 62 % of patients with peripheral malignant lesions. Central lung cancer and benign nodules did not present with such specific patterns. No significant differences in HE were seen between subgroups. Conclusion Pulmonary lesions are characterized by different CES-patterns of arterial supply as evidenced by TE and EE which depends on underlying causes, but CES does not allow to distinguish benign from malignant pleural based lesions in general.

Objective. Second-generation contrast agents have shown spleen-specific uptake. The aim of this study was to investigate the ability of contrast-enhanced sonography (CES) to demarcate splenic lesions in patients with pain in the left upper quadrant (LUQ) and an inhomogeneous splenic texture. Methods. From October 2003 to July 2005, 31 consecutive patients with pain in the LUQ and splenic inhomogeneity on B-mode sonography were studied by CES using a second-generation contrast agent (SonoVue; Bracco SpA, Milan, Italy). The following data were retrospectively evaluated: extent of enhancement (EE) of the spleen and focal splenic lesions was determined and classified, with the EE of surrounding tissue used as an in vivo reference. Focal splenic lesions were classified after CES as round or wedge shaped, solitary or multiple, and anechoic, hypoechoic, or hyperechoic. Results. The EE of the spleen after CES was anechoic (n = 1), hypoechoic (n = 1), or hyperechoic (n = 29). In 16 of 31 patients, focal lesions were seen after CES. The EE of the lesions was anechoic (n = 11) or hypoechoic (n = 5). Lesions were solitary (n = 6) or multiple (n = 10) and round (n = 5) or wedge shaped (n = 11). Final clinical diagnoses of splenic abnormalities were no specific diagnosis (n = 13), complete autosplenectomy (n = 2), splenic lymphoma (n = 5), and splenic infarction (n = 11). The CES diagnoses were confirmed by computed tomography (n = 21), scintigraphy (n = 2), magnetic resonance imaging (n = 1), and clinical follow-up (n = 7). Conclusions. In patients with pain in the LUQ and splenic inhomogeneity, CES enables visualization of splenic abnormalities in more than 50% of the patients; in this group, splenic infarction was the most common diagnosis.

We analyzed the files of all autopsies performed at the Institute of Pathology of the Philipps-University Marburg between 1980 and 1999 with respect to the presence of splenic metastasis. The total number of autopsies within the study period was 8,563. In 1,898 cases, a solid malignant tumor (1,774 carcinomas, 36 sarcomas, 27 malignant melanomas) was diagnosed. Metastasis to the spleen occurred in 57 cases (3.0%). Compared to the whole study population, patients with splenic metastasis were significantly younger (59 years vs. 67 years, p

Objective. Because of the absence of air in atelectatic tissue, sonography allows visualization of lung atelectasis and may characterize pulmonary and bronchial arterial vascularity by contrast-enhanced sonography (CES). Methods. Thirty consecutive patients with obstructive atelectasis (OA) (n = 17) and compression atelectasis (n = 13) were retrospectively studied by CES using a second-generation sulfur hexafluoride contrast agent (SonoVue [BR1], Bracco SpA, Milan, Italy). The following CES parameters were evaluated: (1) time to enhancement (TE) of the contrast agent after intravenous application was determined and classified as short TE and delayed TE (short TE, ≤6 seconds; versus delayed TE, >7 seconds); and (2) extent of enhancement (EE) was evaluated during the arterial phase (2-30 seconds) and the parenchymal phase (1-5 minutes): the EE of pleural lesions was determined in comparison with splenic enhancement and classified in reduced EE versus marked EE. Results. All 13 patients with compression atelectasis had a short TE and a marked EE during arterial and parenchymal phases. In the remaining 17 patients with OA, 10 patients had a short TE and 7 patients had a delayed TE. The EE during both phases was reduced in 5 patients and marked in 3. Nine of 17 patients with OA had different EE during arterial and parenchymal phases. Conclusions. Compression atelectasis is characterized by CES with a short TE and a marked EE, indicating patent pulmonary arterial vascularization. In patients with OA, a variable CES pattern is found. With regard to only the TE, a delayed TE implies OA. This indicates a shifting of pulmonary vascularization to bronchial arterial vascularization in these patients.

Many important articles about fat distribution disorders within the liver have been published in the 1980s and 1990s. However, the diagnostic dilemma of distinguishing diffuse or focal fat distribution disorders especially from malignant neoplasmas persists and is still of clinical relevance. Rare and more common sonographic patterns can be subdivided according to their echogenicity, location, quantity, shape and boundaries by B-mode sonography. The knowledge of the characteristic sonographic patterns of diffuse and focal fat distribution disorders within the liver avoids in most cases costly and more invasive diagnostic procedures. Depending on clinical background in individual cases confirmation of diagnosis of focal fatty liver disease is necessary.

A 19-year-old girl presented with a septical condition with fever of 40 degrees C, swelling of the right sternocleidomastoid region and abdominal pain. Except for a sore throat with pain strictly localized to the right side of her neck and fever over the last week there were no other clues in her past medical history. An abdominal ultrasound and MRT scan as well as a chest X-ray only showed non-specific findings. The diagnosis of Lemierre's syndrome was established by ultrasonographical detection of right jugular venous thrombosis and perivascular inflammation together with blood cultures positive for Fusobacteria. The patient recovered within days after treatment was initiated with metronidazol according to the antibiogram. Lemierre's syndrome is a life-threatening disease especially in an age group which is less frequently affected by septicaemia. A history of sore throat, Fusobacterium positive blood cultures and ultrasonographical detection of jugular venous thrombophlebitis together with the knowledge of the "forgotten disease" will lead the way to the diagnosis.

Purpose The role of respiration in modulating blood flow in the portal vein is unclear. The aim of this study was to investigate the phenomenon of respiration-dependent periodic hepatofugal portal venous blood flow as detected on color Doppler sonography. Methods Within 1 year, we identified 13 patients with respiration-dependent reversal of blood flow in the portal vein that was diagnosed on color Doppler sonography. This phenomenon was investigated by color Doppler sonographic examination of the portal venous flow during both mid-inspiration breath-holding and a respiratory cycle including deep inspiration; evaluation of hepatic vein Doppler waveforms as normal (triphasic) or decreased (flattened); and echocardiographic examination to determine the presence or absence of tricuspid regurgitation. Results The patients' median age was 53 years (range, 26–87 years). Seven of the 13 patients had heart disease (tricuspid regurgitation) with or without liver disease, 3 had liver disease without heart disease, and 3 had other diseases with no evidence of heart or liver disease. On Doppler sonography, 10 of the 13 patients had increased portal venous pulsatility (7 of the 10 had tricuspid regurgitation; the other 3 did not); the remaining 3 patients had neither increased pulsatility nor tricuspid regurgitation. Sonographic follow-up within 4 weeks in 4 of the 13 patients revealed loss of the respiration-dependent hepatofugal portal flow. Conclusions Respiration-dependent hepatofugal portal flow is a rare finding associated with periodic portal hypertension in patients with right heart insufficiency and liver disease. Its clinical significance is unclear. Among our patients, its occurrence was predominantly associated with an increased venous pulsatility index due to tricuspid regurgitation or venous outflow obstruction. Further study is needed to investigate whether periodic respiration-dependent hepatofugal portal flow is predictive of the occurrence of continuous flow reversal. © 2004 Wiley Periodicals, Inc. J Clin Ultrasound 32:62–68, 2004

A nodular tumor of the spleen in patients with myeloproliferative disease (MPD) is a very rare form of splenic involvement. The aim of the study was to describe the clinical data, sonographic patterns, and prognosis of nodular splenic infiltration in patients with MPD.During a 20-year period, nodular splenic lesions were found in 10 out of 183 patients with MPD. Retrospectively, splenic size, echomorphology of the lesions, clinical data, sonographic follow-up, and survival were analyzed.In 9 out of 10 patients the lesions were hyperechoic--in one patient hypoechoic. In 3 patients the lesions were solitary. Seven patients had multiple nodular lesions. Low platelet count was seen in 8 patients; blast crisis was seen in 7 patients. The mean survival time was 2.9 months after detection of the splenic lesions. In one patient, autopsy confirmed the diagnosis of myelosarcoma of the spleen.The appearance of nodular splenic lesions in MPD is associated with blast crisis and a short survival. Definite histologic or cytologic findings associated with splenic nodules in MPD have not been identified yet. Myelosarcoma of the spleen is the most probable diagnosis suggested.

Purpose The aim of this study was to describe the incidence, causes, sonographic features, therapy, and prognosis of nontraumatic intrasplenic pseudoaneurysms (NTISPs), a rare complication of splenic infarction or infiltration by malignant systemic disorders or infectious diseases. Methods We retrospectively reviewed the medical and sonographic records of all patients seen at our clinic from July 1985 through December 2000 to identify patients with a sonographic diagnosis of spontaneous nontraumatic splenic rupture. We then examined the features of the resulting cases to identify patients in whom NTISPs were revealed by color Doppler sonography. Results In total, 41 patients were identified. Among those patients, 5 (12%) had NTISPs. Three of those 5 patients had an underlying malignant disorder (1 case of non-Hodgkin's lymphoma and 2 cases of chronic myelogenous leukemia), and the other 2 had an inflammatory disease (1 case of endocarditis and 1 case of pancreatitis). Three of the patients also had splenic infarctions. Three patients underwent splenectomy; in 2 of them, secondary delayed splenic rupture occurred before or during splenectomy. In 2 other patients, spontaneous thrombosis of the aneurysms occurred (after 16 hours in 1 and 15 days in the other). Conclusions NTISPs may occur in about 12% of patients with sonographically detected nontraumatic spontaneous splenic rupture. NTISPs appear to be associated with an increased risk of secondary delayed splenic rupture, although spontaneous thrombosis may occur. Short-term follow-up sonographic examinations, particularly with color Doppler imaging, are recommended for early recognition of progression of NTISPs, which can guide treatment decisions. © 2003 Wiley Periodicals, Inc. J Clin Ultrasound 31:129–134, 2003

Purpose Functional hyposplenia or asplenia (FAS) can be associated with potential fatal infections. The diagnosis of FAS is traditionally made on liver-spleen scintigraphy and finding Howell-Jolly bodies within erythrocytes. In this retrospective study, our goal was to identify any characteristic sonographic findings of the spleen in patients with FAS in an attempt to determine whether the diagnosis of FAS can be made sonographically. Methods In a review of all medical and sonographic records from the period of January 1, 1985, through December 31, 2001, we identified 24 patients (11 men, 13 women) in whom FAS had been diagnosed by liver-spleen scintigraphy (n = 13) or the finding of Howell-Jolly bodies (n = 11). The following sonographic parameters were determined: size of spleen (small, normal, or large), echotexture of the spleen (homogeneous versus inhomogeneous), echogenicity (isoechoic versus hyperechoic), presence of focal splenic lesions, and patterns of splenic vascularization as determined by color Doppler sonography (absent flow, hilar flow, or parenchymal flow). Results The spleen was small in 20 patients (83%) and normal in the other 4 (17%). Echotexture was homogeneous in 13 patients (54%) and inhomogeneous in 11 (46%). The spleen was isoechoic in 18 cases (75%) and hyperechoic in 6 (25%). Six patients (25%) had focal lesions. Color Doppler sonography showed absent flow in 4 patients (17%), hilar flow in 17 (71%), and hilar and parenchymal vascularization in 3 (12%). Conclusions Sonographic findings in the spleen of patients with FAS are characterized predominantly by a small spleen with absence of parenchymal vascularization on color Doppler sonography in most cases. Future prospective studies will be necessary to confirm these findings and to determine whether FAS can be diagnosed reliably with sonography. © 2003 Wiley Periodicals, Inc. J Clin Ultrasound 31:152–155, 2003

Doppler ultrasound is a well established method for assessment of the portal venous system to detect the direction of portal blood flow. It is helpful for non-invasive diagnosis of intra-abdominal portosystemic shunts, especially in patients with cirrhosis. Less attention has been paid to other influences on portal venous flow, e.g. tricuspid regurgitation, increased hepatic out-flow resistence, respiratory cycle. The aim of this pictorial review is to describe the spectrum of physiological and pathological Doppler ultrasound flow patterns in the portal venous system.

Background: the sonographic pattern of bacterial pneumonia is predominantly well known and characterized by an air bronchogram, a marked vascularity on color Doppler sonography, and a high-impedance arterial flow pattern on Doppler spectral analysis. Methods: in a retrospective study the sonographic findings in seven patients with peripheral BAC on X-ray examination were evaluated in relation to number, size, margins, echomorphology and sonographic arterial flow patterns of the lesions. Results: the following sonomorphologic characteristics were found: multiple foci ( n =4), single foci ( n =3), smooth margins ( n =5), irregular margins ( n =2) and maximal diameter of size (range 5–15 cm). The echomorphology of the lesions was homogenously hypoechoic ( n =1) or showed airbronchograms ( n =6). Color Doppler sonography revealed a vascular tree pattern ( n =5) or a marked presence of blood vessels ( n =2). Doppler flow spectral analysis of arteries in investigated patients ( n =5) demonstrates a high impedance (triphasic) flow pattern in four patients and a low impedance (monophasic) flow pattern in one patient. Conclusions: these findings indicate that BAC frequently shows a sonographic pattern of ‘pneumonia’.

Introduction Retrospective analysis of sonographic patterns of renal lymphoma in B-mode imaging and contrast-enhanced ultrasound (CEUS). Patients/methods From January 2000 to June 2014, 27 patients with clinical or histologically confirmed renal lymphoma were examined with B-mode imaging, followed by CEUS in 8 cases. Results In B-mode imaging renal lymphoma were hypoechoic in all 27 cases (100%). 9 patients (33.3%) had a bilateral, 18 (66.7%) patients had an unilateral lymphoma infiltration of the kidneys. 8 (29.6%) cases of small nodular, 5 (18.5%) cases of large nodular and 6 (22.2%) cases of perirenal lymphoma infiltration of the kidney were observed in B-mode imaging. Bulky-formation of renal lymphoma was detected in 6 (22.2%) patients and 2 (7.4%) patients had a diffuse lymphoma infiltration of the kidneys. In CEUS an arterial isoechoic enhancement was observed in 5 (62.5%)- and, an arterial hypoechoic enhancement was observed in 3 (37.5%) cases of renal lymphoma. A hypoechoic enhancement in the parenchymal phase was observed in 8 (100%) cases of renal lymphoma infiltration. Conclusion In B-mode-imaging, nodular lymphoma infiltration of the kidneys is the most common of all renal lymphoma patterns in B-mode imaging. In CEUS, renal lymphoma presented an arterial iso- or hypoechoic enhancement, followed by a hypoechoic enhancement in the parenchymal phase. In regard to the differentiation of renal lymphoma to benign lesions of the kidney, CEUS may be helpful. However, the differentiation of renal lymphoma from other malignant lesions of the kidney like renal cell carcinoma is not feasible by CEUS.

Functional hyposplenia/asplenia is a severe longterm complication after allogeneic stemcell transplantation predominantly seen in patients who suffer from extensive chronic graft versus host disease (cGvHD). The risk of acquiring an overwhelming infection with encapsulated bacteria is ca. four fold increased in patients with functional hyposplenia/asplenia. Therefore follow up of patients who have received allogeneic blood stem cells (bone marrow or peripheral blood stem cells) should embrace screening for functional hyposplenia. When functional hyposplenia is diagnosed triple vaccination against streptococcus pneumonia, Haemophilus influenza type B and Meningococcus neisseria should be considered. Goldstandard in diagnosing functional hyposplenia is hepatosplenic scintigraphy. We present the case of 37 year old female in whom sonography was indicative of functional hyposplenia. The diagnosis was confirmed by scintigraphy. Sonography including color coded duplex sonography is a safe and cost saving procedure. Sensitivity, Specificity and predictive value of the following sonographic finding: a) decreasing splenic size and b) diminished or absent parenchymal blood flow are currently evaluated in a prospective study.