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.

The value of contrast-enhanced ultrasound in differentiating benign from malignant retroperitoneal masses.

OBJECTIVES: To evaluate the value of contrast-enhanced ultrasound (CEUS) perfusion patterns in the differentiation of benign and malignant retroperitoneal masses (RMs). METHODS: Between 2006 and 2023, 122 consecutive patients with an RM visualizable by B-mode US were investigated additionally with CEUS. On CEUS, the extent of enhancement (classified as marked, reduced, or absent) and the homogeneity of enhancement (HE; classified as homogeneous or inhomogeneous) were evaluated. Subsequently, the malignancy rate according to CEUS perfusion patterns was determined. RESULTS: On CEUS, marked enhancement was significantly more frequently associated with malignancy than with benignity (p < 0.0001, Fisher's exact test). All lesions with no enhancement were benign. Regarding HE, there was no significant difference between benign and malignant lesions (p = 0.07, Fisher's exact test). CONCLUSION: On CEUS, marked enhancement in an RM may be indicative of a malignant lesion. Furthermore, absent enhancement can be considered to be an indication of benignity. The use of CEUS can be helpful in the evaluation of the malignancy of retroperitoneal masses.

The value of contrast-enhanced ultrasound in percutaneous biopsy of retroperitoneal masses.

PURPOSE: To evaluate the diagnostic yield of contrast-enhanced ultrasound (CEUS)-guided biopsy of retroperitoneal masses (RMs). MATERIALS AND METHODS: Between 2006 and 2023, 87 patients presented at our US center for biopsy of an RM. In all biopsies, CEUS was performed prior to the intervention. The technical success rate of biopsy, the presence of diagnostic tissue in solid tumor biopsy samples, the accuracy of the biopsy and the occurrence of post-interventional complications were evaluated. RESULTS: A US-guided biopsy could be conducted in 84/87 cases (96.6%). In 3/87 cases (3.4%), US-guided biopsy was impossible because the planned needle path was obstructed by vital structures. Of 84 lesions, 80 (95.2%) were solid lesions, and 4 (4.8%) were lesions containing fluid. In all solid tumors, 80/80 (100%), diagnostic vital tissue was successfully obtained. CEUS-guided biopsy showed a sensitivity of 93.2%, a specificity of 100%, a positive predictive value of 100%, a negative predictive value of 72.2%, and a diagnostic accuracy of 94.2% for the differentiation between malignant and benign RMs. In one of the 84 cases (1.2%), there was a complication of postinterventional abdominal pain. CONCLUSION: Percutaneous CEUS-guided biopsy is a safe procedure with a high diagnostic yield and a low complication rate.

Contrast-enhanced ultrasound of the liver: Vascular pathologies and interventions. / Kontrastmittelunterstützte Sonografie der Leber: vaskuläre Pathologien und Interventionen.

Over the past two decades, contrast-enhanced ultrasound (CEUS) has been established as a method complementary to B-mode ultrasound and color Doppler sonography for diagnosing vascular liver pathologies and interventions.The objective of this review is to elucidate the application of CEUS in diagnosing vascular pathologies and interventional procedures.Considering the limitations of ultrasound, CEUS presents a similar alternative to other imaging modalities, such as computed tomography and magnetic resonance imaging, for evaluating vascular pathologies, guiding interventions, identifying complications, and assessing outcomes post intervention. Due to its widespread availability and the absence of radiation exposure, CEUS should be employed as a primary modality. · CEUS plays an important role in the detection of vascular liver pathologies.. · CEUS is helpful in characterizing vascular pathologies.. · CEUS is helpful in guiding interventions and identifying complications..

Prevention of life-threatening bleeding complication from splenic venous ectasia by B-mode-, color Doppler- and contrast-enhanced ultrasound in a patient with ALL.

Aim of the study: Spontaneous splenic rupture is a serious complication of pathologically altered spleen tissue, associated with a high mortality rate. Case description: We describe a spontaneous splenic rupture in a patient with acute lymphoblastic leukemia undergoing chemotherapy. Ultrasound revealed splenomegaly, and diffuse splenic acute lymphoblastic leukemia-infiltration was suspected. In addition, only color Doppler sonography and contrast-enhanced ultrasound diagnosed splenic vascular ectasias with a venous-flow-profile. During therapy, short-term sonographic follow-up examinations were able to reveal an increase in the size of venous ectasias and the associated increased risk of spontaneous splenic rupture. Based on these sonographic findings, immediate surgical splenectomy was performed in the spontaneous splenic rupture case and the patient survived. Conclusions: Ultrasound is an important diagnostic method in patients with newly diagnosed malignant hematological diseases to detect disease-related splenic pathologies. Short-term follow-up examinations of splenic vascular pathologies can detect size progression and a potential risk of spontaneous splenic rupture with life-threatening bleeding.

Acoustic Radiation Force Impulse (ARFI) Elastography of Focal Splenic Lesions: Feasibility and Diagnostic Potential.

PURPOSE: Nontraumatic focal splenic lesions (FSL) are rare, and the need for tissue diagnosis must be weighed against the very high risk of bleeding after a splenic biopsy. The aim of this study was to explore the feasibility and diagnostic potential of acoustic radiation force impulse (ARFI) elastography as a noninvasive method for different benign and malignant FSLs. No human studies on the elastographic characteristics of FSL exist. METHODS: This was a retrospective analysis of 34 patients with FSLs, who underwent abdominal B-mode ultrasound (B-US), contrast-enhanced ultrasound (CEUS), and standardized ARFI examinations between October 2021 and December 2022 at our university hospital. The inclusion criteria were: (i) FSL size ≥ 1 cm; (ii) 10 valid ARFI measurements of the FSL, as well as of the normal splenic parenchyma (NSP) as an in vivo reference; and (iii) diagnostic confirmation of FSL etiology based on histological examination (8/34; 23.5%) or clinical evaluation, which included a clinical and sonographic follow-up (FU), CEUS morphology, and/or morphology on cross-sectional imaging (26/34; 76.5%). CEUS was performed on all patients and the FSLs were classified according to the current guidelines; cross-sectional imaging was available for 29/34 (85.3%). The mean FU duration was 25.8 ± 30.5 months. The mean ARFI velocity (MAV) of the FSL (MAVL), the NSP (MAVP), and the ratio of the MAVL to the MAVP (MAVL/P) were calculated and compared. RESULTS: Of the 34 FSLs, 13 (38.2%) were malignant (mFSL) and 21 (61.8%) were benign (bFSL). The MAVL of all 34 FSLs (2.74 ± 0.71 m/s) was lower than the MAVP (3.20 ± 0.59 m/s), p = 0.009, with a mean MAVL/P ratio of 0.90 ± 0.34. No significant differences in the MAVL were observed between the mFSL (2.66 ± 0.67 m/s) and bFSL (2.79 ± 0.75 m/s). There were also no significant differences between the MAVP in patients with mFSL (3.24 ± 0.68 m/s) as compared to that in the patients with bFSL (3.18 ± 0.55 m/s). Likewise, the MAV L/P ratio did not differ between the mFSL (0.90 ± 0.41 m/s) and bFSL (0.90 ± 0.30 m/s) groups. CONCLUSION: ARFI elastography is feasible in evaluating the stiffness of FSLs. The lesions' stiffness was lower than that of the NSP, regardless of the FSL etiology. However, differentiation between benign and malignant FSL with the help of this elastographic method does not appear possible. Larger prospective studies are needed to validate these findings.

B-Mode Ultrasound and Contrast-Enhanced Ultrasound for the Detection of Splenic Involvement in Hodgkin Lymphoma: A Retrospective Analysis of 112 Patients.

PURPOSE: To assess splenic involvement using B-mode ultrasound (US) and contrast-enhanced ultrasound (CEUS) compared with standard imaging with contrast-enhanced computerized tomography (CT) / 18-fluorodeoxyglucose positron-emission tomography (PET-CT) in patients with Hodgkin lymphoma. MATERIALS AND METHODS: Imaging data from 112 patients from 12/2003 to 10/2022 with histologically confirmed Hodgkin lymphoma during staging or relapse were analyzed for splenic lymphoma involvement. In all patients, standard imaging (CT/PET-CT), along with B-mode US and CEUS examinations, was performed. Evidence of focal splenic lesions (FSLs) found by imaging procedures was suggestive of splenic involvement. Follow-up imaging was performed in each patient after treatment, and treatment response indicated definitive splenic involvement. RESULTS: 40 patients (35.7%) were identified by imaging modalities as having splenic involvement, which was confirmed by response during follow-up. Standard CT/PET-CT imaging detected splenic involvement in 36/112 patients (32.1%). FSLs were detected with B-mode US in 38 patients (33.9%) and CEUS in 36 patients (32.1%). The sensitivity of standard imaging, B-mode US, and CEUS was 90%, 95%, and 90%, respectively. CONCLUSION: B-mode US examination is a diagnostic method used in addition to standard imaging for the detection of splenic involvement in Hodgkin lymphoma. CEUS does not provide additional benefit compared to B-mode US and the standard reference procedure.

B-mode ultrasound and contrast-enhanced ultrasound for evaluation of pneumonia: A pictorial essay.

Due to their often peripheral pleural-based location, pneumonias can be visualised by B-mode ultrasound. Therefore, sonography can be used as an alternative imaging modality to chest X-ray in suspected cases of pneumonia. Depending on the clinical background of the patient, and various underlying pathological mechanisms, a heterogeneous pattern of pneumonia is seen in both B-mode lung ultrasound and contrast-enhanced ultrasound. Here, we describe the spectrum of sonographic manifestations of pneumonic/inflammatory consolidation on B-mode lung ultrasound and contrast-enhanced ultrasound.

Inflammatory Pseudotumor of the Omentum in Contrast-enhanced Ultrasound.

Aim of the study: Inflammatory pseudotumor is a rare benign tumor that can occur at various body sites. Due to its rare occurrence and histological variety radiological data is heterogeneous and limited. Case description: We present a case of a 71-year-old man with inflammatory pseudotumor of the omentum. Contrast-enhanced ultrasound perfusion pattern showed homogeneous, isoechoic enhancement in the arterial phase with a washout phenomenon in the parenchymal phase, mimicking a peritoneal carcinomatosis. Conclusions: Inflammatory pseudotumor represents a rare, but important benign differential diagnostic option when considering a malignant disorder. Contrast-enhanced ultrasound is helpful in identifying vital tissue for a targeted biopsy for subsequent histological examination that is essential for the exclusion of malignancy.

Hepatic perivascular epithelioid cell tumor (PEComa): contrast-enhanced ultrasound (CEUS) characteristics-a case report and literature review.

Perivascular epithelioid cell tumors (PEComa) are rare mesenchymal neoplasms that arise from soft tissue of various organs such as the stomach, intestines, and lungs. We report a rare case of a primary PEComa of the liver and its characteristics on contrast-enhanced ultrasound (CEUS) in a 51-year-old female patient with an incidental finding of a hypoechoic liver lesion with peripheral hypervascularization on Doppler ultrasound. CEUS showed homogenous hypervascularity in the arterial phase that was consistent in the portal phase. In the late phase, a central washout phenomenon was evident. Histopathologic findings on sonographic biopsy of the lesion revealed a mesenchymal tumor with positivity for melanocytic markers Human Melanin Black-45 (HMB45) and Melan-A consistent with a PEComa. Despite the absence of high-risk features for malignancy, surgical resection was recommended due to the uncertain malignant potential of PEComas. The patient refused the operation and preferred sonographic follow-up; the lesion was stable over a period of 2 years. CEUS can provide valuable information regarding PEComa. After histological confirmation, the choice between resection and a watchful waiting must be made on individual basis.

Portal venous gas detection in different clinical situations.

Portal Venous Gas (PVG) provides an important differential diagnosis in the diagnose of intrahepatic reflexogenic structures. This review article is intended to provide an overview of the current literature on the detection of PVG, its special forms and important differential diagnoses, it also shows possibilities for the diagnostic procedure in the case of sonographic detection of PVG.

Evaluation and Classification of Incidentally Detected Splenic Lesions Based on B-Mode and Contrast-Enhanced Ultrasound.

PURPOSE: To evaluate B-mode ultrasound (B-US) and contrast-enhanced ultrasound (CEUS) patterns of focal splenic incidentalomas (FSIs), and to correlate ultrasound patterns with benignity and malignancy via histologic examination and/or the clinical course. MATERIALS AND METHODS: Between 2004 and 2021, 139 consecutive patients with an FSI detected by B-US were investigated additionally with CEUS. On CEUS, the arterial enhancement (AE) of the FSI (hyperenhancement, isoenhancement, hypoenhancement, and absent enhancement) was analyzed. Subsequently, the malignancy rate according to different B-US echo patterns and CEUS perfusion patterns was determined. RESULTS: The final diagnosis of FSI was malignant in 9/139 (6.5%) and benign in 130/139 (93.5%) cases. The hypoechoic and hyperechoic lesions on B-US with arterial hyperenhancement on CEUS and the echogenic cystic or complex lesions on B-US with predominantly absent enhancement on CEUS were benign in 54/54 (100%) cases. 6/37 (16.2%) hypoechoic lesions on B-US with arterial hypo-/isoenhancement on CEUS and 3/48 (6.3%) of hyperechoic lesions on B-US with an arterial hypo-/isoenhancement on CEUS were malignant. CONCLUSION: Based on these results, FSIs reveal different malignancy rates depending on the B-US und CEUS patterns, and classification according to these B-US and CEUS patterns may be helpful in further evaluation of an FSI.

Secondary sclerosing cholangitis and IgG4-sclerosing cholangitis - A review of cholangiographic and ultrasound imaging.

Sclerosing cholangitis (SC) represents a spectrum of chronic progressive cholestatic diseases of the intrahepatic and/or extrahepatic biliary system characterized by patchy inflammation, fibrosis, and stricturing. Primary and secondary SC must be distinguished given the different treatment modalities, risks of malignancy, and progression to portal hypertension, cirrhosis, and hepatic failure. This review focuses on secondary SC and the pathogenic mechanisms, risk factors, clinical presentation, and novel imaging modalities that help to distinguish between these conditions. We explore the detailed use of cholangiography and ultrasound imaging techniques.

[Hyposplenism, an underrecognised immune diffeciency: Is sonography helpful?] / "Hyposplenie", eine weitgehend unerkannte Immunschwäche: Ist die Sonografie hilfreich?

The immunodeficiency syndrome of functional hyposplenia/asplenia is frequently unrecognized. The gold standard procedure for the diagnosis of this disease is technetium-99m scintigraphy of heat-denatured erythrocytes and the detection of pitted erythrocytes or Howell-Jolly bodies. Initial work suggests that this clinical presentation is associated with a small spleen. The aim of this review is to describe the value of B-mode and contrast-enhanced ultrasound in the identification of immunodeficiency caused by functional hyposplenism.

Ultrasound Elastography for Characterization of Focal Liver Lesions.

Focal liver lesions (FLL) are typically detected by conventional ultrasound or other imaging modalities. After the detection of FLL, further characterization is essential, and this can be done by contrast-enhanced imaging techniques, e.g., contrast-enhanced ultrasound (CEUS) and magnetic resonance imaging (MRI) or by means of biopsy with histological evaluation. Elastographic techniques are nowadays integrated into high-end ultrasound systems and their value for the detection of severe liver fibrosis and cirrhosis has been shown in studies and meta-analyses. The use of an ultrasound elastographic technique for the differentiation of malignant and benign liver tumors is less well-established. This review summarizes the current data on utility and performance of ultrasound elastography for the characterization of FLL.

HCC or Something Else? Frequency of Various Benign and Malignant Etiologies in Cirrhotic Patients with Newly Detected Focal Liver Lesions in Relation to Different Clinical and Sonographic Parameters.

Background and Aims: To investigate the frequency of different benign and malignant focal liver lesions (FLLs) in relation to clinical and sonographic features among patients with liver cirrhosis (LC) and newly detected FLLs. Methods: This study was a retrospective analysis of 225 cirrhotic patients with newly detected FLLs who underwent hepatic ultrasound (US) examinations at our university hospital from 2011 to 2022. The diagnosis of FLLs was based on histology and/or consensus radiological criteria, in accordance with the current diagnostic guidelines. The FLLs were classified into benign (bFLLs) or malignant (mFLLs) lesions and the latter group was subclassified into HCC and non-HCC mFLLs. The frequency, clinical parameters, and sonographic features of the different groups were examined and compared. Results: Of the 225 FLLs, 154 (68.4%) were mFLLs and 71 (31.6%) bFLLs. HCC was the most frequent subcategory of FLLs (132; 58.7%). There were (22; 9.8%) non-HCC mFLLs with 11 (4.9%) metastases and 11 (4.9%) non-HCC primary liver tumors. Regenerative nodules (RNs) were the most frequent form of bFLLs (25; 11.1%), followed by simple cysts (22; 9.8%) and hemangiomas (14; 6.2%). The other bFLLs (10; 14.1%) were fat deposition/sparing (5), hematomas (2), abscesses (2), and echinococcal cysts (1). The distribution of bFLLs and HCC and non-HCC mFLLs varied significantly according to the clinical scenarios. HCC mFLLs were more frequent in males (p = 0.001), in those with no history of active non-hepatic primary malignant disease (NHPMD) (p < 0.001), in those with a hepatitis B or C etiology of LC (p = 0.002), when located in the right lobe (p = 0.008), and when portal vein thrombosis was present (p = 0.03). Conclusion: In cirrhotic patients with newly detected FLLs, the non-HCC etiology was more frequently diagnosed in lesions that were located in the left lobe, in females, and in patients with a history of active NHPMD. Thus, the lower frequency of HCC in the abovementioned groups demonstrated that a cautious implementation of the current consensus radiological criteria would be required for these groups, particularly in patients with an active NHPMD, given the fact that the consensus criteria were not validated in these populations. A more active diagnostic approach may ultimately be needed for these patients. Large prospective studies are needed to validate these findings.

ARFI elastography of the omentum: feasibility and diagnostic performance in differentiating benign from malignant omental masses.

OBJECTIVE: To evaluate the feasibility and diagnostic performance of acoustic radiation force impulse (ARFI) elastography in different omental masses (OM). DESIGN: This was a retrospective analysis of 106 patients with OM defined as omental thickness ≥1 cm, who underwent abdominal B-mode ultrasound (US) and standardised ARFI examinations of the OM between September 2018 and June 2021 at our university hospital. A cytohistological confirmation was available in 91/106 (85.8%) of all OM, including all 65/65 (100%) malignant OM (mOM) and 26/41 (63.4%) of benign OM (bOM). In 15/41 (36.6%) of bOM; cross-sectional imaging and or US follow-up with a mean duration of 19.8±3.1 months was performed. To examine the mean ARFI velocities (MAV) for potential cut-off values between bOM and mOM a receiver operating characteristic analysis was implemented. RESULTS: The MAV in the mOM group (2.71±1.04 m/s) was significantly higher than that of bOM group (1.27±0.87 m/s) (p<0.001). Using 1.97 m/s as a cut-off yielded a sensitivity and specificity of 76.9% and 85.4%, respectively, in diagnosing mOM (area under the curve=0.851, 95% CI=0.774 to 0.928). CONCLUSION: ARFI elastography is feasible in the omentum and may represent a good non-invasive additional tool in differentiating bOM from mOM.

The Value of Contrast-Enhanced Ultrasound (CEUS) in the Detection of Perfusion Disturbances in Abdominal Wall Hernias Compared with Surgical and Histological Assessment.

Purpose: This study aimed to evaluate the value of contrast-enhanced ultrasound (CEUS) in the evaluation of perfusion disturbance in irreducible abdominal wall hernias (AWHs). Methods: From 2006 to 2018, 50 patients with an irreducible AWH were examined using B-mode ultrasound (B-US) and CEUS. The ultrasound findings were correlated with subsequent surgical and histological results. The presence of non-enhanced areas (NEAs) in hernia contents on CEUS and the presence of non-perfused areas (NPAs) on surgical and histological evaluation were analyzed retrospectively. Results: On CEUS, 13/50 hernia contents (26.0%) revealed NEAs during complete CEUS examination and 37/50 (74.0%) revealed no NEAs during CEUS examination. On surgical and histological evaluation, NPAs in hernia contents were identified in 11/13 cases (93.3%) with NEAs on CEUS. CEUS was found to have a sensitivity of 100.0%, a specificity of 94.9%, a positive predictive value of 84.6%, and a negative predictive value of 100.0% for the identification of perfusion disturbance in AWHs. Conclusions: The findings of this study demonstrate that using CEUS as an imaging method may be helpful for evaluating the perfusion of hernia contents in incarcerated AWHs. On CEUS, the presence of NEAs may suggest perfusion disturbance in hernia contents.