EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part I. General Aspects (Short 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).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part I. General Aspects (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 (long version).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part II. Diagnostic Ultrasound-Guided Interventional Procedures (Short Version).

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/ short version; the long version is published online).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part II. Diagnostic Ultrasound-Guided Interventional Procedures (Long Version).

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).

Guideline for Technical Quality Assurance (TQA) of ultrasound devices (B-Mode)--version 1.0 (July 2012): EFSUMB Technical Quality Assurance Group--US-TQA/B.

The Technical Quality Assurance group was initiated by the EFSUMB Board in 2007 and met firstly in 2008 to discuss and evaluate methods and procedures published for performing technical quality assurance for diagnostic ultrasound devices. It is the aim of this group of experts to advise the EFSUMB Board of effective and efficacious methods for routine use and to make recommendations regarding the technical aspects of EFSUMB by-law 9, parts 11.6. & 11.7. The group's work focused on new developments and related European projects to establish a common guideline. There is a great need of a well established protocol and dedicated processing software for the performance testing of medical ultrasound equipment. The measurements should be user independent as much as physically possible. Only if these goals are achieved in an international (firstly European) context, the optimal quality of ultrasound imaging can be offered and maintained to the medical community. This guideline aims to offer and summarize suitable procedures and evaluation processes to lend support for an optimal Technical Quality Assurance (TQA) scheme. The content of this guideline was presented to the EFSUMB Board of Directors (delegates) and approved by the EFSUMB Executive Board (ExB) at the regular meeting during EUROSON 2012 in Madrid April 2012.

Sonography versus palpation in the detection of regional lymph-node metastases in patients with malignant melanoma.

High-resolution real-time sonography was done in 217 patients with malignant melanoma to compare its value in detecting regional lymph-node metastases with that of palpation. Lymph-node metastases were found in 29 patients by ultrasound whereas, by palpation, metastases were detected in 15 patients only. The presence of metastases was proven by histopathology after surgical lymphadenectomy in these ultrasound positive cases. Thus sonography was superior to palpation, and in addition permitted distinction between metastatic changes and inflammatory lymph-node enlargement. Ultrasound is recommended for preoperative staging as well as in postoperative monitoring of patients with malignant melanoma.

Combined modality treatment of advanced cancers of the oral cavity and oropharynx.

From May 1985 to June 1988, 70 evaluable patients with advanced squamous cell cancers of the oral cavity and the oropharynx were treated with preoperative combined radio-chemotherapy. Treatment consisted of 50 Gy/25 fractions/5 weeks, combined with concomitant administration of mitomycin C on day 1 (15 mg/m2, i.v. bolus) and 5-fluorouracil during the first 5 days of irradiation (750 mg/m2/24 hours, continuous infusion). Surgery was performed 3 to 5 weeks following irradiation. Treatment tolerance was good and local mucosal reaction was increased, but no major systemic side effects were recorded. At surgery, 3-5 weeks following irradiation, 48.6% of the operation specimens did not contain any histologically detectable residual tumor. Overall survival is 61%, being 69% in T2 and T3, while none of the patients with bone invasion has survived. Median survival is 28, 26, and 9 months in T2, T3 and T4 stages, respectively. Loco-regional relapses have been recorded in 33% of the patients, occurring in 27% of T2, 25% of T3, and 88% of T4 stages. Patients have been spared mutilating radical neck dissection because of combined presurgical treatment without impaired survival or loco-regional relapse rate.

Ultrasound of the neck.

Sonography, when performed by an experienced examiner, can be used for evaluation of many pathologies in the head and neck area. Some benign neck lesions, such as cysts, lipomas, carotid body tumors, and hyperplastic lymph nodes, have typical sonomorphology. Sonography has an accuracy rate of about 90% in cervical lymph node staging and can delineate subclinical lymph node recurrences. It is the method of choice for evaluation of tumor infiltrations of the wall of the great vessels. Salivary gland tumors in the superficial lobe can be delineated completely by sonography. Salivary stones can be detected and localized. Carcinoma of the tongue and floor of the mouth with T1 and T2 staging can be assessed by US. The use and contribution of color Doppler sonography for the assessment of pathologic entities in the neck is a method under clinical investigation. US-guided fine-needle aspiration biopsy of lymph nodes and tumors of the salivary glands is easy to perform and is characterized by high sensitivity and specificity. To perform US examinations of the head and neck area of the highest quality the examiner should be familiar with the anatomy of the head and neck, be informed about the clinical problem, and have experience in the interpretation of abnormal US findings. US of the head and neck area is one of the most difficult sonographic examinations and should be performed by an experienced physician.

Sonography of the thyroid and parathyroid glands.

Sonography is the first line modality for assessment of thyroid and parathyroid pathologies. Sonographic and color Doppler patterns of diffuse and focal pathologies of the thyroid are presented in this article. The accuracy of sonography in the localization of enlarged parathyroid glands is also discussed. The limitations of sonography in specifying focal thyroid diseases and the problems in localizing ectopic parathyroid adenoma are addressed.

Small hepatocellular carcinomas in patients with liver cirrhosis: potentials and limitations of contrast-enhanced power Doppler sonography.

Detection and characterization of focal liver lesions are critical for patients with liver cirrhosis. The potential of contrast-enhanced sonography in the characterization of focal liver lesions is well established in the literature. However, prospective studies in the assessment of patients with suspected hepatocellular carcinoma (HCC) in liver cirrhosis are rare. B-mode imaging often cannot differentiate small focal lesions in cirrhotic livers. Also, power Doppler is not capable of characterizing small focal lesions in cirrhosis. Contrast-enhanced sonography with a first-generation enhancer seems to improve the accuracy of diagnosis of small HCC. The differentiation of HCC and dysplastic nodules is notoriously difficult. In addition, other arterial hypervascularized liver lesions should be considered, depending on the clinical background. The limitations and drawbacks of contrast-enhanced sonography should be considered. All imaging methods are of limited value in the detection of solid liver lesions smaller than 1 cm.

New signs of breast cancer: high resistance flow and variations in resistive indices evaluation by color Doppler sonography.

In a prospective study, color Doppler sonograms (CDS) were performed in 142 patients with solid breast lesions (64 carcinomas, 53 fibroadenomas, 25 miscellaneous breast diseases). Exclusively intratumoral RI were determined, with only the highest and lowest value in the various vessels of a tumor being considered. We found that an RI < 0.80 is typical for benign breast conditions, but also frequently occurs in malignant lesions. A significant difference was seen for higher RIs. An RI > or = 0.80 was seen to be an indicator of malignancy with high specificity (96%) and a sensitivity of 55%. Moreover, RI differences in malignant lesions were markedly greater than in benign lesions. An RI difference > or = 0.20 among vessels of one tumor was a malignancy indicator with very high specificity (97%) but relatively low sensitivity (39%). An RI > or = 0.80 and RI differences > or = 0.20 are specific Doppler ultrasound (US) malignancy indicators.

Color Doppler sonography of normal breasts: detectability of arterial blood vessels and typical flow patterns.

In a prospective study, 200 healthy female breasts were examined using color Doppler sonography to study the detectability and the resistive indices (RIs) of arterial vessels. In each breast, we attempted to detect two to three vessels and recorded the frequency spectrum with RI of each vessel. Blood vessels (n = 522) could be demonstrated in 196 (98%) breasts. Continuous diastolic flow (RI < 1) was found in 520 (99.6%) vessels. The mean RI of premenopausal women was 0.64; that of postmenopausal women was 0.70. This difference is highly statistically significant (p < 0.0001), but there is a marked overlap between the RIs of both groups. The variation in RI values of all women (up to 0.45), as well as in the breasts of the same woman (up to 0.31), was considerable. We conclude that modern color Doppler devices permit the detection of blood flow in the breast with regularity. Continuous diastolic flow (RI < 1) is a typical flow pattern. The variations of RI between women, and even for the same woman, are remarkable. The mean RI of premenopausal women is lower than the value for postmenopausal women.

Suture granulomas: sonography enables a correct preoperative diagnosis.

The purpose of this study was to examine if suture granulomas display distinct sonographic signs and if these signs enable an accurate preoperative diagnosis. In a retrospective and prospective study, the sonographic findings of 22 consecutive suture granulomas were investigated and correlated with subsequent operative results. The sonographic appearance of various surgical sutures in a water bath was also investigated. Sonography was performed with commercially available 5- to 13-MHz linear transducers. The sonographic findings of the suture granulomas included hypoechoic lesions in all cases and hyperechoic double or single lines within the hypoechoic lesions in 20 of 22 cases. Sonography enabled the correct preoperative diagnosis for the investigating radiologists in 20 cases. The sonographic appearance of sutures in a water bath was that of hyperechoic double or single lines. The sonographic signs of suture granulomas (hyperechoic double or single lines within hypoechoic lesions) indicate the correct preoperative diagnosis in a high percentage of cases.

Histological grading of therapy induced regression in squamous cell carcinomas of the oral cavity. A morphological and immunohistochemical study.

Squamous cell carcinomas in the oral cavity and the oropharynx were diagnosed in 84 patients. After verification by biopsy, 79 of these patients were treated preoperatively with mitomycin C and 5-fluro-uracil, radiated and operated 3-5 weeks later. The effectiveness of adjuvant preoperative radio-chemotherapy was evaluated histologically. Serial sections of the entire tumor specimen were investigated and the percentage of vital cancerous tissue in the total tumor area was assessed. Regression was classified into four grades. Grades I and II were regarded as good response to adjuvant preoperative radio-chemotherapy, while grades III and IV stood for bad or no response. Morphologically questionable residual tumor infiltrates could be clarified by immunohistochemical methods with antibodies against vimentin, desmin and Lu-5. The histological assessment of the regression grade of operated tumor specimens allows a clinically relevant, morphologically exact and reproducible evaluation of the effect of preoperative radiochemotherapy.

[The diagnosis of salivary gland lipoma]. / Zur Diagnostik von Speicheldrüsenlipomen.

8 patients with 9 lipomas of the salivary gland were reviewed retrospectively. The clinical diagnosis, the sonomorphology and the appearance in CT were analysed. By means of palpation none of the lipomas was specifically diagnosed. Usually sonography is the first imaging method in superficial salivary gland tumors. Therefore the knowledge of the sonomorphology is important for indicating CT. Sonographically a lipoma of the salivary gland should be suspected, if an oval shaped, slightly hypoechoic tumor with a typical feathered appearance and good compressibility is visualized. All lipomas of the salivary glands could be delineated sonographically. Due to their negative homogeneous attenuation values lipomas can be diagnosed specifically in CT. This enables the head and neck surgeon to avoid an operation in patients with no or minor complaints.

[Sonographic assessment of tumorous infiltrations of the extracranial carotid artery]. / Sonographische Beurteilung tumoröser Infiltrationen der extrakraniellen A. carotis.

The role of sonography in evaluation of tumorous infiltrations of the wall of the cervical arteries is discussed upon 75 patients with histologically proved lymphnode metastasis. Direct signs for the infiltration--loss of the echogenic wall of the arteries and indirect signs--length and circumference of the tumor/vessel contact area are evaluated. In 9 patients the infiltrations were correctly diagnosed, 4 patients were false positive. The technic of the sonographic investigation and potential pitfalls are demonstrated. The role of other investigation modalities are discussed.

[Occlusion or stenosis of the splenoportal axis. Supplementary information with duplex sonography?]. / Verschluss oder Stenose der splenoportalen Achse. Zusatzinformation durch Duplexsonographie?

In 21 patients with sonographic signs of occlusions or stenoses of the splenoportal axis additionally pulsed Doppler measurements in the region of the splenic and portal veins were conducted with a Duplex system. Examinations using the pulsed Doppler Duplex system yield functional data in respect of blood flow in addition to the analysis of morphological changes. It is possible to differentiate between cystic structures and collaterals as well as to assess residual perfusions or cavernous transformations in vascular occlusions. Besides qualitative information on blood flow in a vessel and determination of the direction of blood flow, quantitative data on the acceleration of blood flow in stenosis are also possible.

[Spontaneous fatty tissue necrosis of the omentum majus and epiploic appendices: clinical, ultrasonic and CT findings]. / Die spontane Fettgewebsnekrose von Omentum majus und Appendices epiploicae: Klinisches Bild, Ultraschall- und CT-Befunde.

UNLABELLED: To describe US and CT findings of primary epiploic appendicitis and segmental infarction of the omentum. MATERIAL AND METHODS: From 1986 through 1996 thirteen patients presented with these pathological findings at our institution (6 patients with greater omental infarction and 7 patients with epiploic appendicitis). US (n = 13) and CT findings (n = 7) were retrospectively reviewed. RESULTS: US revealed moderately hyperechoic, ovoid lesions adherent to the peritoneum. On CT scans the masses appeared as areas of fat with slightly increased attenuation and sometimes with hyperattenuating peripheral rims. Secondary omental or appendiceal involvement caused by inflammation of adjacent organs has to be excluded. CONCLUSION: Segmental infarction of the omentum and primary epiploic appendicitis have characteristic US and CT features that enable the correct diagnosis.

[CT staging of laryngeal carcinoma]. / CT-Staging des Larynxkarzinoms.

In the pre-operative staging of laryngeal carcinoma CT is of great clinical importance. We examined 20 cases of laryngeal cancer. In 20% of the cases, the CT evaluation indicated more advanced stages, thereby correcting the results of clinical staging. In 65% of the cases, clinical staging showed the same results as CT. 3 glottis tumours (15% of the patients) could not be identified by CT.

[Value and indications for high-resolution real-time sonography in nontumor salivary gland diseases]. / Stellenwert und Indikation der hochauflösenden Real-time-Sonographie bei nichttumorösen Speicheldrüsenerkrankungen.

308 patients with salivary gland diseases were investigated using real-time sonography. In 142 patients we suspected neoplasms of the salivary glands on the sonograms. In the remaining 166 patients we investigated the following entities: sialolithiasis (74 patients), acute sialadenitis (54 patients), abscess formation (16 patients), chronic sialadenitis or autoimmune disease (53 patients) and cysts of salivary gland (5 patients). The changes in the sonographic morphology of the different diseases will be described. The role of ultrasound in the diagnosis of the different diseases will be discussed and the indications for sonographic investigations are summarised.