Peripheral Pulmonary Lesions in Confirmed Pulmonary Arterial Embolism: Follow-up Study of B-Mode Ultrasound and of Perfusion Patterns Using Contrast-Enhanced Ultrasound (CEUS).

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 < .05). CONCLUSION: B-LUS follow-up showed that, in patients with confirmed PE, PPLs had a delayed regression. On CEUS follow-up examination, various perfusion patterns of PPLs were observed, indicating the different ages and the variable reparative processes of pulmonary infarction. In PPLs independent of the underlying signs and symptoms, follow-up B-LUS and CEUS examinations may be helpful for a possible retrospective diagnosis of peripheral pulmonary infarction suggestive of PE.

Contrast-enhanced ultrasound is helpful for differentiating benign from malignant parietal pleural lesions.

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 < 0.001). In five cases, due to the absence of enhancement, it was not possible to determine the HE. In the remaining cases, 9/20 benign and 19/38 malignant lesions showed an inhomogeneous enhancement (p = 0.79). CONCLUSION: On CEUS, marked enhancement was significantly more frequently associated with malignant compared with benign lesions. However, some benign lesions, such as chronic inflammatory processes, may also show a marked enhancement. Therefore, the interpretation of perfusion patterns in these lesions must always take into account the clinical background of the patient.

Mediastinal Masses in Contrast-Enhanced Ultrasound - Retrospective Analysis of 58 Cases.

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).

Perfusion Patterns of Peripheral Pulmonary Lesions in COVID-19 Patients Using Contrast-Enhanced Ultrasound (CEUS): A Case Series.

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.

Use of the Prostate Health Index and Density in 3 Outpatient Centers to Avoid Unnecessary Prostate Biopsies.

OBJECTIVES: We investigated the diagnostic efficacy of the prostate health index (PHI) and PHI density (PHID) to avoid unnecessary prostate biopsies in 3 urological practices. METHODS: In 122 patients, total prostate-specific antigen (PSA), free PSA (f-PSA), the quotient from total PSA and f-PSA (f-PSA%), and [-2]pro-PSA were measured in the serum; PHI, PHID, and PSA density (PSAD) were calculated prior to prostate biopsy. Tissue sampling via transrectal biopsy was indicated in case of suspicious PSA (progression and/or elevation of PSA) and/or suspicious digital rectal examination. PSAD, PHI, and PHID were not used for biopsy indication. The diagnostic efficacy was determined with receiver-operating characteristic (ROC)and decision curve analyses. RESULTS: Based on prostate biopsies, 38% (n = 46) of the cases had no prostate carcinoma (PCa), 21% (n = 26) no clinically significant (insignificant) PCa, and 41% (n = 50) had clinically significant PCa. ROC analyses of the PSA parameters showed higher diagnostic efficacy for PHI and PHID (AUC 0.722 and 0.739) than for f-PSA%, PSA, and PSAD (AUC 0.612, 0.595, and 0.698, respectively) regarding carcinoma diagnosis. With a combined use of PHI and PHID (cutoff >40 and >0.9, respectively), only 1 clinically significant PCa would have been missed (sensitivity 98%); in 24 (20%) patients, biopsy could have been avoided. CONCLUSION: The integration of PHI and PHID could improve the diagnostic efficacy of risk calculators to avoid unnecessary prostate biopsies. However, as a prerequisite, validation of cutoff values in prospective studies is urgently required.

Use of Ultrasound in the Diagnostic Work-Up of Adult Intussusception - A Multicenter Retrospective Analysis.

PURPOSE: To evaluate the use of ultrasound (US) in the diagnostic work-up of adult intussusception (AI). METHODS: This multicenter study includes 26 consecutive patients diagnosed with AI between January 2010 and November 2017. A retrospective chart analysis was conducted with a focus on abdominal US findings and diagnostic accuracy of different imaging modalities (ultrasound, computed tomography (CT), magnetic resonance imaging). If available, surgical and pathological findings served as the gold standard (76.9 %). US examiners certified according to DEGUM grade 2 or 3 were classified as experts. Otherwise, they were regarded to have basic skills. RESULTS: During diagnostic work-up, 92.3 % underwent abdominal US. US was the first-line imaging modality in 88.5 % of cases. The accuracy regarding the detection of AI (85 %), correct localization (95 %) and detection of complications (100 %) was excellent and comparable with CT (81 %, 90.5 %, and 91.7 %) when performed by experts. 72.7 % of tumorous lead points were detected by experienced examiners. In contrast, AI was detected in only 45.5 % of cases by examiners with basic skills. AI was diagnosed prior to surgery in all patients. CONCLUSION: US is reliable in the diagnostic work-up of AI when performed by experienced examiners with high-quality equipment. US, CT and MRI should be used in a complementary fashion since combination provides excellent sensitivity regarding the detection and correct localization of AI as well as the detection of complications. The impact of real-time imaging is illustrated by supplementary videos.

Hospital volume in ureterorenoscopic stone treatment: 99 operations per year could increase the chance of a better outcome-results of the German prospective multicentre BUSTER project.

BACKGROUND: Despite the high utilisation of ureterorenoscopy (URS) in interventional stone treatment, there is little evidence of any link between annual hospital volume and outcome. METHODS: From January to April 2015, data from 307 URS patients were prospectively recorded in the multicentre observational BUSTER-Trial (Benchmarks of ureterorenoscopic stone treatment-results in terms of complications, quality of life, and stone-free rates). The best threshold value for annual hospital volume with an independent effect on the outcome (measured on stone-free and complication rates) of our study group was established with logistic regression. RESULTS: In 38.4% of cases of renal and 61.6% of ureteral stones, median stone size was 6 mm with an interquartile range (IQR) of 4-8 mm. The annual URS rate in the 14 participating hospitals ranged from 77 to 333 (median 144; IQR 109-208). The binary endpoint as a combination of completely stone-free or residual fragments small enough to pass spontaneously and a maximum complication severity of Clavien-Dindo grade 1 was attained in 234/252 (92.9%) cases with a hospital volume of ≥ 99 URS compared with 43/55 (78.2%) in < 99 URS (p = 0.002). Adjusted for patient-, stone- and physician-related factors, an annual hospital URS volume of ≥ 99 increases the chance of an optimum outcome (OR = 3.92; 95% CI 1.46-10.51; p = 0.007). CONCLUSIONS: An independent effect of URS hospital volume on outcome quality in the 14 participating hospitals was demonstrated. Threshold values for annual case numbers should be scientifically established irrespective of the considered procedure.

Ureteroenteric strictures: a single center experience comparing Bricker versus Wallace ureteroileal anastomosis in patients after urinary diversion for bladder cancer.

BACKGROUND: To evaluate the outcome and complication rate in a single institution experience using the two most commonly used techniques of ureteroenteric anastomosis, the Bricker and Wallace anastomosis. METHODS: A total of 137 patients underwent ileal conduit for bladder cancer. Ureters were anastomosed by two experienced surgeons, one performing a Bricker and the other, a Wallace anastomosis. Stricture was identified during clinical follow-up. RESULTS: Seventy-five patients underwent a Bricker anastomotic, and 65 received a Wallace anastomosis. The average age was 70 in both groups, males were predominant (66% Bricker, 70% Wallace). Follow up period was 36.5 months in Bricker group and 17 months in Wallace group. In both groups, the body mass index (BMI) was similar (26.1 kg/m2 Bricker and 26.4 kg/m2 Wallace). We observed that the stricture rate after performing the Bricker anastomosis technique was 25.3% (19/75) as compared to 7.7% (5/65) after Wallace anastomosis technique, which was statistically significant (p = 0.001). In the Bricker group, patients with strictures had higher BMI (28.3 vs. 25.7 kg/m2, p = 0.05). On average it took 8.5 months in the Bricker group and three months in the Wallace group (p = 0.6) to develop stricture. CONCLUSIONS: The stricture rate was significantly higher when Bricker technique was applied. Although the BMI was not different in both groups, patients with a higher BMI were more likely to develop stricture. We believe that the approach of the separate and refluxing technique of Bricker anastomosis especially in obese patients poses a higher risk for anastomotic stricture formation.

RANKL/RANK/OPG cytokine receptor system: mRNA expression pattern in BPH, primary and metastatic prostate cancer disease.

BACKGROUND: The cytokine system RANKL (receptor activator of NF-κB ligand), its receptor RANK and the antagonist OPG (osteoprotegerin) play a critical role in bone turnover. Our investigation was conducted to describe the gene expression at primary tumour site in prostate cancer patients and correlate the results with Gleason Score and PSA level. METHODS: Seventy-one samples were obtained from prostate cancer patients at the time of radical prostatectomy and palliative prostate resection (n = 71). Patients with benign prostate hyperplasia served as controls (n = 60). We performed real-time RT-PCR after microdissection of the samples. RESULTS: The mRNA expression of RANK was highest in tumour tissue from patients with bone metastases (p < 0.001) as compared to BPH or locally confined tumours, also shown in clinical subgroups distinguished by Gleason Score (< 7 or ≥ 7, p = 0.028) or PSA level (< 10 or ≥ 10 µg/l, p = 0.004). RANKL and OPG mRNA expression was higher in tumour tissue from patients with metastatic compared to local disease. The RANKL/OPG ratio was low in normal prostate tissue and high tumours with bone metastases (p < 0.05). Expression of all three cytokines was high in BPH tissue but did not exceed as much as in the tumour tissue. CONCLUSION: We demonstrated that RANK, RANKL and OPG are directly expressed by prostate cancer cells at the primary tumour site and showed a clear correlation with Gleason Score, serum PSA level and advanced disease. In BPH, mRNA expression is also detectable, but RANK expression does not exceed as much as compared to tumour tissue.

Nephron sparing surgery for renal cell carcinoma up to 7 cm in the context of guideline development: a contribution of healthcare research.

INTRODUCTION: If technically feasible, organ-preservation is indicated for T1 renal cell carcinoma (RCC), since partial nephrectomy (PN) is equivalent to radical nephrectomy with regard to tumor-specific survival and probably achieves better overall survival. Treatment results of a training clinic were assessed with regard to guideline adherence and treatment quality. METHODS: Based on 220 open interventions in the time periods 2006-2009 (TP1) and 2010-2013 (TP2), a retrospective single center examination was performed to determine the influence of patient-age, sex, BMI, ASA-score, preoperative eGFR, PADUA-score and surgeon's experience on PN-rate and trifecta-outcome (R0 resection, warm ischemia time ≤25 min, no intraoperative complications and no blood-transfusion and postoperative complications grade ≤1 Clavien and Dindo). RESULTS: PN-rate increased from 36.1 % in TP1 to 72.4 % in TP2. Despite significantly higher PADUA-scores in TP2 than in TP1 (p = 0.0038), the trifecta-rate did not differ significantly (TP1 65.7 %; TP2 70.8 %; p = 0.666). Only the PADUA-score exerted an independent influence on the endpoints "organ-preservation" and "trifecta-outcome". CONCLUSIONS: This study again demonstrated that the PADUA-score is a robust predictor of technical feasibility and treatment outcome for open PN. Consistent implementation of guidelines for nephron sparing surgery in RCC ≤7 cm is possible even in the setting of a training clinic and need not be associated with compromised treatment quality despite the increasing level of difficulty. Depending on the author, there are various definitions of trifecta-outcome. A uniform trifecta-concept would be desirable.

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.

Intracavitary contrast-enhanced ultrasound in abscess drainage--feasibility and clinical value.

OBJECTIVE: To evaluate the usefulness of intracavitary-applied contrast-enhanced ultrasound (ICCEUS) with BR1 in ultrasound-guided puncture and drainage of abdominal and pelvic abscesses. MATERIAL AND METHODS: A total of 71 consecutive patients received ICCEUS after placement of a drainage catheter or a needle in abdominal or pelvic abscesses. Portions of 0.1 ml of BR1 and 20 ml of saline were injected through the drainage catheter or needle. Ultrasound recordings were evaluated to answer the following questions: correct placement of the catheter by showing enhancement in the cavity and the drain - ICCEUS findings suggesting incomplete enhancement in all abscess cavities - enhancement in non-abscess structures. RESULTS: About 52% of patients had liver, 14% of patients had intraperitoneal, 11% had subphrenic, 14% had retroperitoneal, 6% had splenic, and 4% had pelvic abscesses. The majority of the patients received drain placement with 10-F using trocar technique. Enhancement in the drain or needle was seen in all patients. In 2% of patients, during the initial approach, a dislodgment of the catheter from the abscess cavity was diagnosed. Due to non-enhancing abscess compartments, in 36% of the patients more than one drainage treatment was necessary at the time of the first approach. In 14% of the patients communication with surrounding structures was diagnosed. Additional treatment resulted in 4% of cases. CONCLUSION: ICCEUS was helpful in all patients to confirm correct placement of drain or puncture needle. In 40% of patients, as a consequence of ICCEUS, additional therapy was scheduled, either additional drainage or abscess puncture, endoscopic retrograde drainage of the biliary or pancreatic duct or thoracic intervention.

Ultrasound during Advanced Life Support-Help or Harm?

Ultrasound is used in cardiopulmonary resuscitation (CPR) and advanced life support (ALS). However, there is divergence between the recommendations of many emergency and critical care societies who support its use and the recommendations of many international resuscitation organizations who either recommend against its use or recommend it only in limited circumstances. Ultrasound offers potential benefits of detecting reversable causes of cardiac arrest, allowing specific interventions. However, it also risks interfering with ALS protocols and increasing unhelpful interventions. As with many interventions in ALS, the evidence base for ultrasound use is weak, and well-designed randomized trials are needed. This paper reviews the current theory and evidence for harms and benefits.

Lung Ultrasound and Pleural Artifacts: A Pictorial Review.

Lung ultrasound is a well-established diagnostic approach used in detecting pathological changes near the pleura of the lung. At the acoustic boundary of the lung surface, it is necessary to differentiate between the primary visualization of pleural parenchymal pathologies and the appearance of secondary artifacts when sound waves enter the lung or are reflected at the visceral pleura. The aims of this pictorial essay are to demonstrate the sonographic patterns of various pleural interface artifacts and to illustrate the limitations and pitfalls of the use of ultrasound findings in diagnosing any underlying pathology.

Student ultrasound education, current view and controversies. Role of Artificial Intelligence, Virtual Reality and telemedicine.

The digitization of medicine will play an increasingly significant role in future years. In particular, telemedicine, Virtual Reality (VR) and innovative Artificial Intelligence (AI) systems offer tremendous potential in imaging diagnostics and are expected to shape ultrasound diagnostics and teaching significantly. However, it is crucial to consider the advantages and disadvantages of employing these new technologies and how best to teach and manage their use. This paper provides an overview of telemedicine, VR and AI in student ultrasound education, presenting current perspectives and controversies.

Ultrasound in bone fracture diagnosis - a comparative meta-analysis and systematic review.

AIM: This meta-analysis evaluates the diagnostic accuracy of ultrasound (US) for bone fractures over the past 47 years, comparing it to established imaging standards. MATERIAL AND METHODS: We adhered to PRISMA 2020 guidelines to search Medline, EMBASE, and the Cochrane Library using tailored search strategies. The primary outcome, US diagnostic performance, was analyzed across various subgroups including clinical relevance, patient age, and anatomical considerations. The QUADAS-2 tool was employed to assess study quality and minimize bias. RESULTS: From 5,107 initially identified studies, 75 met the inclusion criteria, encompassing 7,769 participants and 3,575 diagnosed fractures. The majority of studies were prospective (79%) and compared US primarily with plain radiography (76%) and CT scans (19%). Of these, 61 studies were amenable to systematic analysis, revealing US to have a sensitivity and specificity of 91% (95% CI: 90%-92%) and 91.3% (95% CI: 90.5%-92.1%), respectively. Likelihood ratios were favorable, with a positive value of 9.955 and a negative value of 0.087, and an odds ratio of 132.67. The area under the curve stood at 0.9715, indicating high diagnostic accuracy despite significant heterogeneity (I²=81.3% for sensitivity, 89.3% for specificity). CONCLUSION: The evidence supports US as a highly accurate diagnostic tool for bone fractures, rivalling standard imaging methods like CT and radiography. Its notable diagnostic efficacy, combined with advantages in reducing pain, wait times, and radiation exposure, advocates for its broader application. Further validation in large-scale, randomized trials is essential to integrate US more fully into clinical guidelines for fracture management.

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.

Controversies in Endoscopic Ultrasound-Guided Biliary Drainage.

In this 14th document in a series of papers entitled "Controversies in Endoscopic Ultrasound" we discuss various aspects of EUS-guided biliary drainage that are debated in the literature and in practice. Endoscopic retrograde cholangiography is still the reference technique for therapeutic biliary access, but EUS-guided techniques for biliary access and drainage have developed into safe and highly effective alternative options. However, EUS-guided biliary drainage techniques are technically demanding procedures for which few training models are currently available. Different access routes require modifications to the basic technique and specific instruments. In experienced hands, percutaneous transhepatic cholangiodrainage is also a good alternative. Therefore, in this paper, we compare arguments for different options of biliary drainage and different technical modifications.