Student Ultrasound Education, Current Views and Controversies; Who Should be Teaching?

Acquiring diagnostic ultrasound competencies and skills is crucial in modern health care, and achieving the practical experience is vital in developing the necessary anatomy interpretation and scan acquisition skills. However, traditional teaching methods may not be sufficient to provide hands-on practice, which is essential for this skill acquisition. This paper explores various modalities and instructors involved in ultrasound education to identify the most effective approaches. The field of ultrasound instruction is enriched by the diverse roles of physicians, anatomists, peer tutors, and sonographers. All these healthcare professionals can inspire and empower the next generation of ultrasound practitioners with continuous training and support. Physicians bring their clinical expertise to the table, while anatomists enhance the understanding of anatomical knowledge through ultrasound integration. Peer tutors, often medical students, provide a layer of social congruence and motivation to the learning process. Sonographers provide intensive practical experience and structured learning plans to students. By combining different instructors and teaching methods, success can be achieved in ultrasound education. An ultrasound curriculum organized by experts in the field can lead to more efficient use of resources and better learning outcomes. Empowering students through peer-assisted learning can also ease the burden on faculty. Every instructor must receive comprehensive didactic training to ensure high-quality education in diagnostic ultrasound.

Student ultrasound education - current views and controversies.

As an extension of the clinical examination and as a diagnostic and problem-solving tool, ultrasound has become an established technique for clinicians. A prerequisite for high-quality clinical ultrasound practice is adequate student ultrasound training. In light of the considerable heterogeneity of ultrasound curricula in medical studies worldwide, this review presents basic principles of modern medical student ultrasound education and advocates for the establishment of an ultrasound core curriculum embedded both horizontally and vertically in medical studies.

Prevalence of benign focal liver lesions and non-hepatocellular carcinoma malignant lesions in liver cirrhosis.

Liver cirrhosis is associated with an increased risk of developing hepatocellular carcinoma (HCC). However, other benign and malignant liver lesions may co-exist or may be the only focal liver lesion (FLL) detected. Compared to HCC, comparatively little is known about the frequency and natural history of benign FLL in patients with established liver cirrhosis.This review analyses the prevalence and frequency of benign and malignant FLL others than hepatocellular carcinoma (HCC) in liver cirrhosis including imaging and autopsy studies. Understanding these data should be helpful in avoiding misdiagnoses.

[Alternatives of histological material collection - When and how is histological confirmation by ultrasound (US), computer tomography (CT) or endosonography (EUS) useful?] / Alternativen histologischer Materialgewinnung ­ Wann und wie ist die histologische Sicherung mittels Ultraschall (US), Computertomografie (CT) oder Endosonografie (EUS) sinnvoll?

Histological classifications of tumorous lesions together with adequate staging are necessary for stage-appropriate and personalized therapies. The indications, technical possibilities, and limitations as well as potential complications of image-guided needle biopsy by ultrasound, computed tomography, and endosonography are described. Which procedure for which organ and which lesion?

Endoscopic ultrasound elastography of small solid pancreatic lesions: a multicenter study.

BACKGROUND: The prevalence of malignancy in patients with small solid pancreatic lesions is low; however, early diagnosis is crucial for successful treatment of these cases. Therefore, a method to reliably distinguish between benign and malignant small solid pancreatic lesions would be highly desirable. We investigated the role of endoscopic ultrasound (EUS) elastography in this setting. METHODS: Patients with solid pancreatic lesions ≤ 15 mm in size and a definite diagnosis were included. Lesion stiffness relative to the surrounding pancreatic parenchyma, as qualitatively assessed and documented at the time of EUS elastography, was retrospectively compared with the final diagnosis obtained by fine-needle aspiration/biopsy or surgical resection. RESULTS: 218 patients were analyzed. The average size of the lesions was 11 ± 3 mm; 23 % were ductal adenocarcinoma, 52 % neuroendocrine tumors, 8 % metastases, and 17 % other entities; 66 % of the lesions were benign. On elastography, 50 % of lesions were stiffer than the surrounding pancreatic parenchyma (stiff lesions) and 50 % were less stiff or of similar stiffness (soft lesions). High stiffness of the lesion had a sensitivity of 84 % (95 % confidence interval 73 % - 91 %), specificity of 67 % (58 % - 74 %), positive predictive value (PPV) of 56 % (50 % - 62 %), and negative predictive value (NPV) of 89 % (83 % - 93 %) for the diagnosis of malignancy. For the diagnosis of pancreatic ductal adenocarcinoma, the sensitivity, specificity, PPV, and NPV were 96 % (87 % - 100 %), 64 % (56 % - 71 %), 45 % (40 % - 50 %), and 98 % (93 % - 100 %), respectively. CONCLUSIONS: In patients with small solid pancreatic lesions, EUS elastography can rule out malignancy with a high level of certainty if the lesion appears soft. A stiff lesion can be either benign or malignant.

Differential diagnosis of small solid pancreatic lesions.

BACKGROUND AND AIMS: Pancreatic ductal adenocarcinoma (PDAC) is typically diagnosed at a late stage. Little is known about the incidental finding of early-stage PDAC. The aim of the current study was to determine the etiology of small solid pancreatic lesions (≤15 mm) to optimize clinical management. METHODS: Inclusion criterion for the retrospective study analysis was the incidental finding of primarily undetermined small solid pancreatic lesions ≤15 mm in 394 asymptomatic patients. Final diagnoses were based on histology or cytology obtained by imaging-guided biopsy (and at least 12-month follow-up) and/or surgery. Contrast-enhanced US or contrast-enhanced EUS was performed in 219 patients. RESULTS: The final diagnoses of 394 patients were as follows: 146 PDACs, 156 neuroendocrine tumors, 28 metastases into the pancreas from other primary sites, and 64 various other etiologies. Contrast-enhanced US allowed differential diagnosis of PDAC and non-PDAC in 189 of 219 patients (86%). CONCLUSIONS: Approximately 40% of patients with small solid pancreatic lesions had very early stage PDAC. Approximately 60% of small solid pancreatic lesions ≤15 mm are not PDAC and, therefore, do not require radical surgery. Without preoperative diagnosis, an unacceptably large proportion of patients would be exposed to radical surgery with significant morbidity and mortality.

Comments and Illustrations of Ultrasound Findings in Extrapulmonary Tuberculosis Manifestations.

This review describes the appearance of extrapulmonary tuberculosis manifestations in comprehensive and multiparametric ultrasound imaging. The aim is to increase awareness of typical ultrasound findings regarding extrapulmonary tuberculosis, correlate those with pathological features, and facilitate differential diagnosis. Point of care ultrasound protocols can be used as a screening method in high-risk populations, although the negative findings do not exclude tuberculosis. Conversely, the diagnosis of extrapulmonary tuberculosis can never be made using ultrasound alone, as many ultrasound findings in extrapulmonary tuberculosis are non-specific. However, ultrasound-based sampling techniques can significantly facilitate the collection of samples for microbiological or molecular proof of tuberculosis, as well as facilitating the establishment of alternative diagnoses.

Comments and Illustrations of the European Federation of Societies for Ultrasound in Medicine (EFSUMB) Guidelines: Rare Malignant Pulmonal and Pleural Tumors: Primary Pulmonary Sarcoma and Mesothelioma, Imaging Features on Transthoracic Ultrasound.

Primary pulmonary sarcoma and mesothelioma are rare malignancies. The review article discusses the appearance of these tumors in B-mode ultrasound (US), color Doppler ultrasound and contrast-enhanced ultrasound (CEUS). In particular, the article is intended to inspire the examination of thoracic wall tumors and pleural masses with the possibilities of ultrasonography and to obtain histologically evaluable material using US or CEUS-guided sampling.

WFUMB Review Paper. Incidental Findings in Otherwise Healthy Subjects, How to Manage: Liver.

An incidental focal liver lesion (IFLL) is defined as a hepatic lesion identified in a patient imaged for an unrelated reason. They are frequently encountered in daily practice, sometimes leading to unnecessary, invasive and potentially harmful follow-up investigations. The clinical presentation and the imaging aspects play an important role in deciding if, and what further evaluation, is needed. In low-risk patients (i.e., without a history of malignant or chronic liver disease or related symptoms), especially in those younger than 40 years old, more than 95% of IFLLs are likely benign. Shear Wave liver Elastography (SWE) of the surrounding liver parenchyma should be considered to exclude liver cirrhosis and for further risk stratification. If an IFLL in a low-risk patient has a typical appearance on B-mode ultrasound of a benign lesion (e.g., simple cyst, calcification, focal fatty change, typical hemangioma), no further imaging is needed. Contrast-Enhanced Ultrasound (CEUS) should be considered as the first-line contrast imaging modality to differentiate benign from malignant IFLLs, since it has a similar accuracy to contrast-enhanced (CE)-MRI. On CEUS, hypoenhancement of a lesion in the late vascular phase is characteristic for malignancy. CE-CT should be avoided for characterizing probable benign FLL and reserved for staging once a lesion is proven malignant. In high-risk patients (i.e., with chronic liver disease or an oncological history), each IFLL should initially be considered as potentially malignant, and every effort should be made to confirm or exclude malignancy. US-guided biopsy should be considered in those with unresectable malignant lesions, particularly if the diagnosis remains unclear, or when a specific tissue diagnosis is needed.

Pancreatic ultrasound: An update of measurements, reference values, and variations of the pancreas.

Reliable and reproducible measurement methods have been established, and reference values are used in almost all scientific disciplines. Knowledge of reference values is crucial to distinguish physiological from pathological processes and, therefore, subsequently, for the clinical management of patients. Image storage and documentation of measurements and normal findings should be part of quality assurance in imaging. This paper aims to review the published literature and provide current knowledge of sonographic measurements and reference values of the pancreas. Moreover, the role of clinical influencing factors such as age, gender, constitution, and ethnicity is also analyzed.

History of contrast enhanced ultrasound (CEUS).

The 50th year of the European Federation of Societies in Ultrasound in Medicine and Biology (EFSUMB) has been celebrated 2022 publishing articles on the history of US. Contrast enhanced ultrasound (CEUS) allows to visualize blood flow and tissue perfusion. CEUS has proven to be safe without risk of nephrotoxicity. The availability of a contrast agent (tracer) for ultrasound imaging allows for the first time a dynamic assessment of tissue perfusion (blood flow and wash-in/wash-out pattern) which is an essential part for the detection and characterisation of pathological tissue and abnormal organ function. It was an outstanding achievement of academic centers in close cooperation with EFSUMB to investigate and validate the clinical potential of this new technology for the diagnosis and monitoring of various diseases and to develop clinical guidelines based on an in-depth assessment of the existing scientific publications. An important part of the implementation of CEUS in clinical practice was the development of contrast-specific imaging modes on the ultrasound scanners (in close cooperation with the machine manufacturers), the optimization of the machine setups for contrast imaging and the education provided to clinical users in form of workshops, webinars, textbooks and scientific congresses.

Comments on and illustrations of the WFUMB CEUS liver guidelines: Rare malignant neuroendocrine and predominant epithelioid liver lesions.

The diagnosis or rare, non-hematologic malignant lesions of the liver may be a challenge owing to the rarity of the disease, and is usually made by histological confirmation. Ultrasound with color Doppler and contrast-enhanced, if required, taking into account the clinical background of the patient, may help to focus the differential diagnosis. In this review, we describe the pathological and ultrasound features of rare malignant neuroendocrine and predominantly epithelioid liver lesions including primary neuroendocrine tumor of the liver, Invasive mucinous cystic neoplasm of the liver, and also hepatoblastoma.

Comments and illustrations of the European Federation of Societies for Ultrasound in Medicine contrast-enhanced ultrasonography guidelines: multiparametric imaging and EUS-guided sampling in rare pancreatic tumors. Mesenchymal pancreatic tumors of intermediate biological behaviour.

The focus of the review is on mesenchymal pancreatic tumors with intermediate biological behavior and their imaging appearance. Similar to benign and malignant mesenchymal pancreatic tumors, these tumors are extremely rare. The diagnosis is often confirmed only by postoperative histology. The very limited data on abdominal ultrasound and EUS findings including contrast-enhanced techniques of these pancreatic lesions are summarized here.

Comments and illustrations of the European Federation of Societies for Ultrasound in Medicine contrast-enhanced ultrasound guidelines: Multiparametric imaging and EUS-guided sampling in rare pancreatic tumors. Benign mesenchymal pancreatic tumors.

The focus of the review is on primary benign mesenchymal pancreatic tumors and their imaging appearance. These tumors are extremely rare. Usually, they are not diagnosed until postoperative histology is available, and so even benign tumors have undergone extensive pancreatic resection. The very limited data on abdominal and EUS findings including contrast-enhanced techniques of these pancreatic lesions are summarized here. Case reports will be presented for some of these rare tumors with application of modern ultrasound and endosonographic techniques.

Comments on and illustrations of the WFUMB CEUS liver guidelines: Rare malignant mesenchymal liver lesions.

The diagnosis or rare mesenchymal malignant lesions of the liver may be a challenge owing to the rarity of the disease and is usually made by histological confirmation. An ultrasound examination with, if required, color Doppler sonography and contrast-enhanced ultrasound, taking into account the clinical background of the patient, may help to focus the differential diagnosis. In this review, we describe the pathological and ultrasound features of several rare mesenchymal malignant liver lesions which include undifferentiated sarcoma of the liver, leiomyosarcoma, angiosarcoma, fibrosarcoma, liposarcoma, and epithelioid hemangioendothelioma.

Comments and illustrations of the European Federation of Societies for Ultrasound in Medicine guidelines: Rare pancreatic tumors, ultrasound and contrast-enhanced ultrasound features-Malignant mesenchymal tumors.

Rare malignant mesenchymal pancreatic tumors are systematized and reported in this review. The focus is on the appearance on imaging. The present overview summarizes the data and shows that not every pancreatic tumor corresponds to the most common entities of ductal adenocarcinoma or neuroendocrine tumor.

Comments and illustrations of the WFUMB CEUS liver guidelines: rare benign hematological focal liver lesions (hepatic extramedullary hematopoiesis, Hemophagocytic lymphohistiocytosis, reactive lymphoid hyperplasia).

The manifestation of benign hematological infiltration in the liver is a challenge due to their rare occurrence and therefore, limited awareness and the general need for biopsy and histological confirmation. Owing to the rarity of these lesions, there are limited data concerning their appearance on ultrasound and, specifically, contrast-enhanced ultrasound. In a series of papers, we have compiled the US and CEUS characteristics of rare FLL, where there are few reports and images available, in order to build up a library of these cases. This paper describes the US and CEUS features of benign hematological FLL which include hepatic extramedullary hematopoiesis (EMH), hemophagocytic lymphohistiocytosis (HLH) and reactive lymphoid hyperplasia (RLH). Although these lesions occur rarely in the liver, their correct identification is imperative for appropriate patient`s management.

Comments and illustrations of the European Federation of Societies for Ultrasound in Medicine contrast-enhanced ultrasound guidelines. Rare pancreatic tumors, imaging features on transabdominal ultrasound and EUS with contrast enhancement: Rare epithelial pancreatic tumors: solid pseudopapillary neoplasm, acinar cell carcinoma, mixed neuroendocrine-non-neuroendocrine neoplasms, some rare subtypes of pancreatic adenocarcinoma and pancreatoblastoma.

Rare malignant pancreatic lesions are systematically reported in this review. The focus is on the imaging appearance of the rare epithelial pancreatic tumors such as the solid pseudopapillary neoplasm, acinar cell carcinoma, rare subtypes of adenocarcinoma, and pancreatoblastoma as seen on ultrasound, EUS, and contrast-enhanced ultrasound or EUS. The present overview summarizes the data and shows that not every pancreatic tumor is likely to be the most common entities of ductal adenocarcinoma or neuroendocrine tumor.

Comments and illustrations of the WFUMB CEUS liver guidelines: Rare benign focal liver lesion, part I.

Improved detection and characterization of common focal liver lesions (FLL) are the main topics of the World Federation for Ultrasound in Medicine and Biology (WFUMB) guidelines on the use of contrast-enhanced ultrasound (CEUS). On stateof-the-art CEUS imaging, to create a library of rare FLL, especially concerning their atypical imaging characteristics, might be helpful for improving clinical diagnostic efficiency. In this review, we aim to summarize the ultrasound and CEUS features of rare benign FLL. Currently there are limited reports and images published.

CEUS Bosniak Classification-Time for Differentiation and Change in Renal Cyst Surveillance.

It is time for a change. CEUS is an established method that should be much more actively included in renal cyst monitoring strategies. This review compares the accuracies, strengths, and weaknesses of CEUS, CECT, and MRI in the classification of renal cysts. In order to avoid overstaging by CEUS, a further differentiation of classes IIF, III, and IV is required. A further development in the refinement of the CEUS-Bosniak classification aims to integrate CEUS more closely into the monitoring of renal cysts and to develop new and complex monitoring algorithms.