Endoscopic mucosal resection and endoscopic submucosal dissection with an external additional working channel (EMR+ and ESD+) are equivalent to using a double-channel endoscope: a systematic evaluation in a porcine ex vivo model.

BACKGROUND AND AIMS: With an external additional working channel (AWC) endoscopic mucosal resection (EMR) as well as endoscopic submucosal dissection (ESD) can be extended to techniques termed "EMR+" and "ESD+." These novel techniques are systematically compared to EMR and ESD under the use of a double-channel endoscope (DC). METHODS: Our trial was conducted prospectively in a pre-clinical porcine animal model (EASIE-R simulator) with standardized gastric lesions measuring 3 or 4 cm. RESULTS: EMR+ and EMR DC showed both good results for 3 cm lesions with no adverse events and an en bloc resection rate of 73.33% (EMR+) and 60.00% (EMR DC, p = 0.70). They came to their limits in 4 cm lesions with muscularis damages of 20.00% (EMR+), 13.33% (EMR DC, p ≥ 0.99) and decreasing en bloc resection rates of 60.00% (EMR+) and 46.67% (EMR DC, p = 0.72). ESD+ and ESD DC were both reliable concerning en bloc resection rates (100% in all groups) and adverse events (0.00% in 3 cm lesions, 12.50% muscularis damages in both ESD+ and ESD DC in 4 cm lesions). Resection time was slightly shorter in all groups with the AWC compared to DC although only reaching significance in 3 cm ESD lesions (p < 0.05*). CONCLUSIONS: With the AWC, a standard endoscope can easily be transformed to double-channel functionality. We could show that EMR+ and ESD+ are non-inferior to EMR and ESD under the use of a double-channel endoscope. Consequently, the AWC presents an affordable alternative to a double-channel endoscope for both EMR and ESD.

[Metastasis or sarcoidosis - a diagnostic pitfall in metastatic rectal carcinoma]. / Metastase oder Sarkoidose ­ eine diagnostische Herausforderung beim metastasierten Rektumkarzinom.

BACKGROUND: Granulomatous diseases as sarcoidosis can impair the staging of metastatic diseases since metastasis are hard to distinguish from granulomas in standard imaging. This case report describes the diagnostic workup and therapy in a patient with simultaneous sarcoidosis and rectal cancer with hepatic metastasis and how a curative stadium was achieved. CASE DESCRIPTION: A 71-year old male patient was diagnosed with an adenocarcinoma of the rectum after presenting with involuntary weight loss and anemia. Further diagnostics raised strong suspicion of hepatic, pulmonary and splenic metastasis. Histology after bronchoscopy surprisingly discovered non-caseating granulomas, leading to the diagnosis of sarcoidosis. Due to an obstructive tumor, a rectum resection was performed. Due to a high suspicion of splenic metastasis during surgery, the spleen was removed. Histology revealed no metastasis in the spleen but multiple granulomas due to sarcoidosis. After surgery, biopsy of a suspicious lesion in the liver revealed both metastasis and sarcoidosis in the same sample. The patient was treated with a pseudo(neo)adjuvant chemotherapy with 5-Fluorouracil, Leukovorin, Oxaliplatin (FOLFOX) and Panitumumab (Anti-EGF-antibody). After treatment, CT scan revealed two hepatic lesions decreasing in size, while all other lesions were metrically stable. A right hemihepatectomy followed and histology revealed both sarcoidosis and metastasis. The curated patient was sent to aftercare and there is no suspicion for a relapse (13 month after last surgery). DISCUSSION: The simultaneous appearance of metastatic tumors and sarcoidosis creates a diagnostic dilemma since both manifestations can barely be distinguished in regular imaging technologies. This case report demonstrates that the histological work-up of affected organs with consecutive resections can cure a patient of a metastatic tumor disease, even in the context of simultaneous sarcoidosis.

[Acute necrotizing pancreatitis with hemorrhagic shock in secondary splenic rupture: a case report and literature review]. / Akute nekrotisierende Pankreatitis mit hämorrhagischem Schock bei sekundärer Milzruptur: Ein Fallbericht und Literaturübersicht.

Atraumatic splenic rupture is a rare complication of acute and chronic pancreatitis. It arises due to its anatomical proximity to the pancreas, for instance, due to erosion of large pseudocysts or walled-of-necrosis (WON).Following we describe the case of a 62-year-old woman who presented for further diagnostics and treatment of acute pancreatitis with the development of large walled-of necrosis (WON) in the pancreatic corpus and tail. During the course, the patient developed a hemorrhagic shock. An emergency computer tomography (CT) of the abdomen revealed a ruptured spleen with a large capsular hematoma with no evidence of active bleeding. In contrast to previous published case reports, our treatment was exclusively minimal-invasive: by radiological guided embolization of the splenic artery and by endosonographic guided implantation of a lumen apposing metal stent (LAMS). The splenic hematoma was spontaneously regressive without secondary drainage.

Induction of remission with tacrolimus in a patient with severe acute, cortisone refractory ulcerative colitis and severe Covid-19 pneumonia: a case report.

BACKGROUND: Therapy regimens used in patients with inflammatory Bowel Disease (IBD) have been associated with enhanced risk of viral infections or viral reactivation. Moreover, it is uncertain whether IBD patients have increased risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or infected patients may have an increased risk for severe coronavirus disease 2019 (Covid-19). Managing severe acute flare in ulcerative colitis during the Covid-19 pandemic is a challenge for clinicians and their patients. The results of the published studies mainly report on the role of the prior medication, but not how to treat severe acute flare of IBD patients with severe Covid-19 pneumonia. CASE PRESENTATION: We report the case of a 68-year-old patient with a long history of ulcerative colitis. He was initially admitted to an external hospital because of severe acute flare. The initiation of a high-dose oral cortisone therapy did not improve the clinical symptoms. During the inpatient treatment, he was tested positive for SARS-CoV-2. At admission to our hospital the patient showed severe flare of his ulcerative colitis and increased Covid-19 symptoms. A cortisone-refractory course was noticed. After detailed multidisciplinary risk-benefit assessment, we initiated an intravenous tacrolimus therapy and dose of prednisolone was tapered gradually. After clinical response, the therapy was adjusted to infliximab. Additionally, the Covid-19 pneumonia was kept under control despite immunosuppression and the patient could be discharged in clinical remission. CONCLUSIONS: This case suggest the use of tacrolimus as a bridging therapeutic option for severe acute, cortisone refractory ulcerative colitis in Covid-19 patients. Nevertheless, the best treatment strategy for IBD patients presenting a flare during the outbreak has yet to be defined. Further data for IBD patients under calcineurin inhibitor therapy are urgently needed.

Liver metastasis mimicking a liver cyst of a thymoma in a 38-year-old immunocompromised patient.

Cystic liver lesions (CLL) are common and, in the majority of cases, benign. However, the range of differential diagnoses of CLL is wide. A combination of medical history, blood test results, and imaging can help find the correct diagnosis. We report the case of a 38-year-old immunocompromised female patient with a history of thymectomy and postoperative radiation 3 years prior due to thymoma. Subsequently, the patient was referred to our department for clarification of a cystic liver lesion. During short-term follow-up, the lesion increased in size, and due to the contrast agent behavior in the ultrasound and MRI examination, the suspicion of a biliary cystadenocarcinoma was considered.Furthermore, imaging showed several subcentimetric liver lesions of unknown dignity. Finally, pericystectomy and atypical partial liver resection was performed. Histology revealed a cystic metastasis of the malignant B3 thymoma and a cavernous hemangioma. Liver metastases of a thymoma are rare, and this is the first case of a cystic liver metastasis of a thymoma. The presented case illustrates that in the management of CLLs beside imaging techniques, the medical history with previous conditions should be considered, especially in past malignancies.

Pathological gallbladder wall thickening is associated with advanced chronic liver disease and independent of serum albumin.

PURPOSE: Increased gallbladder wall thickness (GBWT) is a common finding. Reported causes include advanced chronic liver disease (ACLD), ascites and hypalbuminemia. GBWT is a marker for the prediction of esophageal varices. It remains unclear which of these factors is the decisive driver of GBWT. We aim to investigate whether there is a predominant factor associated with the GBWT. METHODS: We enrolled 258 patients with ascites, hypalbuminemia and/or ACLD and 98 healthy volunteers that underwent abdominal ultrasound. Differences of mean GBWT in subgroups of patients with ACLD, ascites, and/or hypalbuminemia were analyzed. Correlation between various parameters and GBWT were calculated using multiple regression analysis. RESULTS: GBWT in patients with ACLD + ascites + hypalbuminemia (n = 59; 5.70 ± 2.05 mm) was pathologically increased compared to patients with hypalbuminemia + ascites without ACLD (n = 36; 2.14 ± 0.66 mm; p < .001) and to patients with only hypalbuminemia (n = 76; 2.02 ± 0.80 mm; p < .001). GBWT of patients with ACLD + hypalbuminemia (n = 30; 3.42 ± 1.52 mm) and with ACLD and normal albumin level were not different (n = 46; 3.10 ± 1.62 mm; p > .999). Significant correlation was seen between GBWT and ACLD (r = .53; p < .001) and ascites (r = .51; p < .001) but not albumin level (r = .04; p = .510). CONCLUSION: We demonstrate that ACLD is predominantly associated with GBWT. In contrast to the current literature, serum albumin level appears not to be associated with pathological GBWT.

Endoscopic submucosal dissection with an additional working channel (ESD+): a novel technique to improve procedure time and safety of ESD.

BACKGROUND AND AIMS: A new external additional working channel (AWC) was recently introduced by which endoscopic submucosal dissection (ESD) can be converted to a technique termed "ESD+ ". We aim to systematically evaluate this novel technique in flat gastric lesions and compare it to classical ESD. METHODS: The study was prospectively conducted in a pre-clinical ex vivo animal model (EASIE-R simulator) with porcine stomachs. Prior to intervention, we set standardized lesions measuring 3 cm or 4 cm in antegrade as well as in retrograde positions. RESULTS: Overall, 64 procedures were performed by an experienced endoscopist. Both techniques were reliable and showed en bloc resection rates of 100%. Overall, ESD+ reduced time of procedure compared to ESD (24.5 vs. 32.5 min, p = 0.025*). Particularly, ESD+ was significantly faster in retrograde lesions with a median of 22.5 vs. 34.0 min in 3 cm retrograde lesions (p = 0.002*) and 34.5 vs. 41.0 min (p = 0.011*) in 4 cm retrograde lesions. There were 0 perforations with both techniques. In ESD+ , 1 muscularis damage occurred (3.13%) compared to 6 muscularis damages with ESD (18.75%, p = 0.045*). CONCLUSIONS: By its grasp-and-mobilize technique, ESD+ allows potentially faster and safer resections of flat gastric lesions compared to conventional ESD in an ex vivo porcine model. The potential advantages of ESD+ in terms of procedure time may be particularly relevant for difficult lesions in retrograde positions.

Contrast-Enhanced Ultrasound Algorithms (CEUS-LIRADS/ESCULAP) for the Noninvasive Diagnosis of Hepatocellular Carcinoma - A Prospective Multicenter DEGUM Study.

BACKGROUND: This prospective multicenter study funded by the DEGUM assesses the diagnostic accuracy of standardized contrast-enhanced ultrasound (CEUS) for the noninvasive diagnosis of hepatocellular carcinoma (HCC) in high-risk patients. METHODS: Patients at high risk for HCC with a histologically proven focal liver lesion on B-mode ultrasound were recruited prospectively in a multicenter approach. Clinical and imaging data were entered via online entry forms. The diagnostic accuracies for the noninvasive diagnosis of HCC were compared for the conventional interpretation of standardized CEUS at the time of the examination (= CEUS on-site) and the two CEUS algorithms ESCULAP (Erlanger Synopsis for Contrast-enhanced Ultrasound for Liver lesion Assessment in Patients at risk) and CEUS LI-RADS (Contrast-Enhanced UltraSound Liver Imaging Reporting and Data System). RESULTS: 321 patients were recruited in 43 centers; 299 (93.1 %) had liver cirrhosis. The diagnosis according to histology was HCC in 256 cases, and intrahepatic cholangiocarcinoma (iCCA) in 23 cases. In the subgroup of cirrhotic patients (n = 299), the highest sensitivity for the diagnosis of HCC was achieved with the CEUS algorithm ESCULAP (94.2 %) and CEUS on-site (90.9 %). The lowest sensitivity was reached with the CEUS LI-RADS algorithm (64 %; p < 0.001). However, the specificity of CEUS LI-RADS (78.9 %) was superior to that of ESCULAP (50.9 %) and CEUS on-site (64.9 %; p < 0.001). At the same time, the negative predictive value (NPV) of CEUS LI-RADS was significantly inferior to that of ESCULAP (34.1 % vs. 67.4 %; p < 0.001) and CEUS on-site (62.7 %; p < 0.001). The positive predictive values of all modalities were high (around 90 %), with the best results seen for CEUS LI-RADS and CEUS on-site. CONCLUSION: This is the first multicenter, prospective comparison of standardized CEUS and the recently developed CEUS-based algorithms in histologically proven liver lesions in cirrhotic patients. Our results reaffirm the excellent diagnostic accuracy of CEUS for the noninvasive diagnosis of HCC in high-risk patients. However, on-site diagnosis by an experienced examiner achieves an almost equal diagnostic accuracy compared to CEUS-based diagnostic algorithms.

Testing of Helicobacter pylori by Endoscopic Biopsy: The Clinical Dilemma of Suppressive Conditions.

BACKGROUND AND AIMS: Testing for Helicobacter pylori is frequently conducted during esophagogastroduodenoscopy (EGD). Suppressive conditions such as the intake of proton-pump inhibitors (PPIs), preceded antibiotic treatment or recent upper gastrointestinal bleeding impair H. pylori test quality. The aim of our study was to evaluate the frequency and pattern of H. pylori suppressive conditions in a large patient collective undergoing elective EGD in a German university hospital. METHODS: The trial was performed as a single-center study. Only elective EGD from inpatients and outpatients were included. Prior to endoscopy, H. pylori suppressive conditions were collected using a standardized questionnaire. If H. pylori testing was indicated according to the guidelines, always both histology and helicobacter urease test were performed in analogy to the Sydney classification. RESULTS: One thousand six hundred and thirty-one patients were included (median 61 years, 36.0% outpatients, 64.0% inpatients). Overall, 76.5% of patients were under H. pylori suppressive conditions. The main suppressive condition was the intake of PPIs (70.7%). In 819 (50.2%) of all included cases, H. pylori testing was performed. The following were the results: 17.3% (142) had a positive H. pylori testing and 82.7% (677) were negative. Of those with negative result, 70.0% were tested under suppressive conditions. CONCLUSION: Guidelines recommend H. pylori testing under non-suppressive conditions. However, this does not always meet the clinical practice. Our data show that de facto, many patients undergoing elective EGD are tested for H. pylori under suppressive conditions coming along with a higher risk of potentially false negative results. Particularly, concerning this issue, further research is needed to improve and clarify everyday clinical practice.

Prospective comparison of 2D-shearwave elastography in both liver lobes in healthy subjects and in patients with chronic liver disease.

Background/aims: 2D-shearwave elastography is an established method for liver stiffness measurement (LSM). However, the success rate of LSM using the recommended standard technique in the right lobe is limited by several factors. We aimed to compare LSM in the right and left liver lobe in order to evaluate whether LSM in the left lobe could be an alternative if measurements in the right lobe are not feasible. Methods: A total of 116 subjects, 58 healthy volunteers and 58 patients with chronic liver disease (CLD), were prospectively included. LSM were performed in the right lobe and in the left lobe, both in neutral and in inspiration position. Results: LSM in the left lobe (8.39(±4.83)kPa) was significantly (p < .001) higher than LSM in the right lobe (6.27(±2.45)kPa). LSM in inspiration position (8.60(±4.33) kPa) was significantly (p = .009) higher than LSM in neutral position (7.70(±3.01)kPa). LSM in the left lobe overestimated the grade of fibrosis in 50.0% of the patients with CLD. However, correlation between LSM values right and left was strong (r = 0.856) and additional use of LSM in the left lobe increased the success rate from 106/116 (91.4%) to 112/116 (96.6%; p = .098). High skin-to-liver-capsule-distance and presence of ascites were independent risk factors for non-successful LSM. Conclusions: Despite significantly higher values, LSM in the left lobe may be an alternative if LSM in the right lobe is not feasible, and cirrhosis can be ruled out with high probability if LSM is within the normal range.

Evaluation of liver stiffness by 2D-SWE in combination with non-invasive parameters as predictors for esophageal varices in patients with advanced chronic liver disease.

Background/aims: Esophageal varices (EV) are common complications in patients with advanced chronic liver disease (ACLD). Non-invasive parameters to exclude EV in patients with ACLD would be desirable. The aim of this study was the evaluation of liver stiffness measurement (LSM) using 2D-shear wave elastography (GE Logiq E9) and other non-invasive parameters as predictors for EV. Methods: Hundred patients with ACLD were enrolled. Abdominal sonography, including measurement of gall bladder wall thickness (GBWT), spleen diameter and LSM, gastroscopy and blood test results were evaluated. Statistical analyses were performed for the association between EV and non-invasive parameters. Results: Fifty-one per cent of the patients had EV. The mean LSM (14.6 kPa) and GBWT (3.88 mm) in the group with EV were significantly higher than in the group without EV (10.6 kPa; 2.94 mm; p < .01). Performing area under the receiver operating characteristic curve, LSM has a better diagnostic performance (0.781) than GBWT (0.707), spleen diameter (0.672) and platelet count (0.635). Combining LSM (cut-off 13.58 kPa) and GBWT (cut-off 3.07 mm) resulted in a sensitivity of 86.3% and a specificity of 71.4% for the presence of EV. A sensitivity of 100% (negative predictive value 1.0) was achieved at LSM >9 kPa or GBWT >4 mm. Following these criteria in our current study population, 18% of the gastroscopies could have been avoided. Conclusions: Combining LSM with non-invasive parameters, especially GBWT, improves the diagnostic accuracy for predicting EV. We suggest reconsidering screening gastroscopy in patients with ACLD who show LSM <9 kPa and GBWT <4 mm due to the very low risk of having varices.

High Prevalence of Pathological Hydrogen Breath Tests in Patients with Functional Dyspepsia.

BACKGROUND/AIMS: The aim of the study is to investigate the frequency of pathological hydrogen breath tests (HBT) in patients with clinical features of functional dyspepsia (FD) meeting the Rome criteria and normal testing of upper endoscopy and abdominal sonography. METHODS: We retrospectively included patients who underwent HBT (lactose, fructose, or glucose) between 2006 and 2012 and who had symptoms of FD. Patients were divided into 2 groups according to medical history and diagnostic results: (I) patients with suspected FD according to the Rome III criteria and (II) patients with an alternative diagnosis such as gastroesophageal reflux disease (GERD) or Crohn's disease (CD). RESULTS: A total of 207/404 patients were assigned to the FD group and 44.4% of these had at least 1 positive HBT and thus more frequently than patients with GERD (20.7%; n = 111; p < 0.001) and with CD (31.7%; n = 63; p = 0.07). Lactose and fructose HBT, but not glucose HBT, occurred significantly more frequently with pathological results than in patients with GERD (p = 0.02; p = 0.002). The probability of a positive HBT increased significantly with increasing number of performed HBT (p < 0.001). CONCLUSION: We suggest that HBT should be considered in the clinical management of patients with suspected FD. In cases of positive HBTs, a potential causal therapy can be initiated.

Liver Stiffness Measured by 2-Dimensional Shear Wave Elastography: Prospective Evaluation of Healthy Volunteers and Patients With Liver Cirrhosis.

OBJECTIVES: We aimed to establish normal values for liver stiffness measurement, performed by 2-dimensional shear wave elastography (LOGIQ E9; GE Healthcare, Wauwatosa, WI), in healthy volunteers, patients with nonhepatic morbidities, and patients with histologically confirmed liver cirrhosis. METHODS: A total of 175 participants were included between July 2016 and February 2018. Three cohorts were analyzed: healthy volunteers (n = 68), patients with healthy livers but nonhepatic morbidities (n = 57), and patients with liver cirrhosis (n = 50). Liver stiffness measurement was performed by 2 observers with different levels of experience to determine interobserver agreement. RESULTS: Of the 175 participants included, 91 were male, and the mean age ± SD was 44.4 ± 19.4 years. The success rate for 175 liver stiffness measurements was 95.4%. The number of unsuccessful measurements was significantly higher in the liver cirrhosis cohort (P = .04). The interobserver agreement was excellent (intraclass correlation coefficient, 0.87). Liver stiffness in the healthy-liver patient cohort (4.93 ± 0.83 kPa) was not significantly different from that in the healthy-volunteer cohort (5.19 ± 1.03 kPa; P = .13). Apart from male sex in the healthy-volunteer cohort, age, body mass index, mild steatosis, and nonhepatic morbidities had no significant impact on liver stiffness. Liver stiffness values in participants without liver disease (healthy volunteers and healthy-liver patients; n = 125) ranged from 3.62 to 7.02 kPa (2.5th-97.5th percentiles). Notably, there was no overlap of liver stiffness measurements between the patients without liver disease and the cirrhosis cohort (13.29 ± 3.27 kPa [7.76-19.49 kPa]). CONCLUSIONS: Liver stiffness values in healthy individuals vary widely and are not dependent on age, body mass index, or specific nonhepatic comorbidities. Liver stiffness values within the normal range can noninvasively rule out cirrhosis, as liver stiffness is significantly higher in cirrhotic patients (P < .001). Two-dimensional shear wave elastography has excellent interobserver agreement.

Gall bladder wall thickening as non-invasive screening parameter for esophageal varices - a comparative endoscopic - sonographic study.

BACKGROUND: The mortality due to hemorrhage of esophageal varices (EV) is still high. The predominant cause for EV is liver cirrhosis, which has a high prevalence in Western Europe. Therefore, non-invasive screening markers for the presence of EV are of interest. Here, we aim to investigate whether non-inflammatory gall bladder wall thickening (GBWT) may serve as predictor for the presence of EV in comparison and combination with other non-invasive clinical and laboratory parameters. METHODS: One hundred ninety four patients were retrospectively enrolled in the study. Abdominal ultrasound, upper endoscopy and blood tests were evaluated. GBWT, spleen size and the presence of ascites were evaluated by ultrasound. Platelet count and Child-Pugh-score were also recorded. The study population was categorized in two groups: 122 patients without esophageal varices (non EV) compared to 72 patients with EV were analyzed by uni-and multivariate analysis. RESULTS: In the EV group 46% showed a non-inflammatory GBWT of ≥4 mm, compared to 12% in the non-EV group (p < 0.01). GBWT was significantly higher in EV patients compared to the non-EV group (mean: 4.4 mm vs. 2.8 mm, p < 0.0001), and multivariate analysis confirmed GBWT as independent predictor for EV (p < 0.04). The platelets/GBWT ratio (cut-off > 46.2) had a sensitivity and specificity of 78 and 86%, PPV 76% and NPV of 87%, and ROC analysis calculated the AUC of 0.864 (CI 0.809-0.919). CONCLUSIONS: GBWT occurs significantly more often in patients with EV. However, because of the low sensitivity, combination with other non-invasive parameters such as platelet count is recommended.

Mesenteric Masses on 2D Mode and Contrast-Enhanced Ultrasound: A Retrospective Study in 69 Patients.

PURPOSE: 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. MATERIALS AND METHODS: 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. RESULTS: 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 %). CONCLUSION: 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.