Cystic splenic lesions: a sonographic approach-retrospective study in 111 patients.

OBJECTIVES: To describe and categorize splenic cystic-appearing lesions (S-CAL) with B-mode and contrast-enhanced ultrasound (CEUS). MATERIALS AND METHODS: This retrospective study investigated S-CALs in 111 patients between 2003 and 2023 in an interdisciplinary ultrasound center with B-mode ultrasound, color Doppler sonography (CDS), and CEUS. S-CAL was characterized by echogenicity, diameter, and shape, as well as additional features like septation, calcification, or wall thickening, and CDS/CEUS were used to identify perfusion. Histological examination or imaging follow-up was necessary to determine the nature of S-CAL. Moreover, 'S-CAL with risk' was defined, necessitating further procedures. Four types (0-III) of S-CALs were defined based on ultrasound parameters. Fisher's exact test was used to compare non-parametric data. RESULTS: S-CAL of 111 patients (58 female, 53 men-average age: 58.6 years) was examined. Final diagnoses were: splenic cyst (n = 64, 57.7%); splenic abscess (n = 10, 9.0%); intrasplenic pseudoaneurysm (n = 10, 9.0%); splenic metastasis (n = 10, 9.0%); splenic infarction (n = 6, 5.4%); splenic hematoma (n = 4, 3.6%); other (n = 7, 6.3%). S-CAL groupings were type 0 (n = 11, 9.9%), type I (n = 33, 29.7%), type II (n = 24, 21.6%), and type III (n = 43, 38.7%). 'S-CAL with risk' was diagnosed in n = 41 (36.9%). Malignant S-CAL was only seen in type II (n = 2, 8.2%) and type III (n = 9, 20.9%) (p < 0.001). 'S-CALs with risk' were found more frequently in type 0 (n = 11, 100%), type II (n = 16, 66.7%) and type III (n = 13, 30.2%) than in type I (n = 1, 3%) (p < 0.001). CONCLUSION: B-mode ultrasound, CDS, and CEUS are useful to further characterize and follow-up S-CAL and identify 'S-CAL with risk', requiring further procedures. CLINICAL RELEVANCE STATEMENT: Ultrasound imaging is valuable for the detection, categorization, and monitoring of cystic-appearing lesions of the spleen, as well as for the identification of those with risk. KEY POINTS: An S-CAL may introduce uncertainty in clinical practice as imaging-based risk stratification is missing. B-mode and CEUS, along with the clinical context and follow-up, assist in characterizing and identifying 'S-CAL with risk'. S-CALs encompass various lesions, including simple cysts, metastases, abscesses, and intrasplenic pseudoaneurysms.

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.

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.

Prospective Assessment of Treatment-Induced Liver Injury as a Cause of Diffuse Pathologic Hepatic Enhancement in Contrast-Enhanced Ultrasound.

OBJECTIVE: A hypo-enhancement of the liver in contrast-enhanced ultrasound (CEUS), pathologic one-minute hepatic enhancement (pOMHE), was recently observed in 70% of allogeneic hematopoietic stem cell transplantation patients with a high-risk profile for veno-occlusive disease (VOD). Whether pOMHE was a pre-clinical sign of VOD or an unspecific feature of liver damage secondary to intensive chemotherapy is unclear. METHODS: To investigate this, we studied CEUS patterns in patients receiving high-dose chemotherapy prior to autologous hematopoietic stem cell transplantation (auto-HSCT) or intensive induction therapy (IT) for the treatment of acute leukemia. From April 2020 to May 2021, patients undergoing auto-HSCT (n = 20) or acute leukemia patients prior to IT (n = 20) were included. All patients underwent a B-mode ultrasound and CEUS of the liver and spleen before treatment (d0) and on day 10 (d10) after therapy start. The one-minute hepatic enhancement was quantified. An optical density of liver enhancement less than 90% compared with the spleen was considered pathologic (pOMHE). Clinical and laboratory parameters used to assess a drug-induced liver injury (DILI) were documented. RESULTS: The OMHE was normal (d0 and d10) in 36 (90%) patients. After IT, 2 of 20 patients had a pOMHE. A DILI grade IV was diagnosed in one case and hyperfibrinolysis in the second case. In 2 of 20 (5%) auto-HSCT patients a pOMHE was observed at d10 without clinical symptoms. CONCLUSION: Chemotherapy-induced effects are not the cause of a pathologic liver enhancement. In contrast, severe DILI or hyperfibrinolysis can be associated with pOMHE.

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.

Pulmonary Cystic Echinococcosis in Contrast-enhanced Ultrasound - A Case Report.

Aim of the study: Pulmonary cystic echinococcosis is a parasitic infection transmitted by dogs and occurring in livestock-raising areas. It is included among the neglected tropical diseases, according to the World Health Organization. Imaging plays a pivotal role in the diagnosis of this disease. While cross-sectional imaging modalities such as computed tomography and magnetic resonance imaging are preferred, lung ultrasound may be another feasible technique. Case description: We report a case of pulmonary cystic echinococcosis in a 26-year-old woman who was examined by contrast-enhanced ultrasound, which showed marked annular enhancement around the hydatid cyst, mimicking a superinfected cyst. Conclusions: Contrast-enhanced ultrasound examination in pulmonary cystic echinococcosis should be studied in a larger population to determine the value of additional contrast administration. In the present case report, no superinfected echinococcal cyst was seen despite marked annular contrast enhancement.

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.

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.

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.

[Ultrasound systems for abdominal diagnostics - current methods, clinical applications and new technologies]. / Ultraschallgeräte für die abdominelle Diagnostik: neue Techniken und Applikationen ­ Was gibt es? Was ist möglich? Was ist sinnvoll?

Abdominal ultrasound is the method of first choice in many clinical situations. Gray scale imaging (B-mode) and conventional Doppler techniques are nowadays complemented by contrast-enhanced ultrasound (CEUS), elastography, fat quantification and further technologies which allow multimodal characterization of organs and tissue structure using panoramic imaging, 3D-techniques and image fusion. The development of small portable devices augments the spectrum for sonographic diagnostics. In this review, we describe the current status of ultrasound technology based on published evidence. In addition, we provide guidance for quality assurance.

[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.

Presentation of Chloromas in B-Mode Ultrasound and Contrast-Enhanced Ultrasound.

Chloromas, also referred to as myeloid sarcomas, describe rare extramedullary tumor aggregates of malignant myeloid progenitor cells. The aim of this study was investigate the diagnostic features and characteristics of chloromas using contrast-enhanced ultrasound (CEUS). Between July 2007 and April 2021, 15 patients with 20 myeloid neoplasms and suspected chloroma manifestations were examined using B-mode US (B-US) and CEUS. Clinical data and B-US (echogenicity, border, size) and CEUS (hyper-, iso-, hypo- or complex enhancement) characteristics were retrospectively analyzed. Absolute and relative frequencies were determined. In B-US, the chloromas were most frequently hypo-echoic (n = 15, 75%). In addition, a hyperechoic (n = 2, 10%) or echocomplex (n = 3, 15%) presentation was observed. On CEUS, 7 chloromas (35%) had an arterial hyperenhancement, 8 (40%) an iso-enhancement and 3 (15%) a complex enhancement. Two chloromas (10%) did not exhibit any enhancement. We describe for the first time CEUS and B-US patterns of chloromas. They are typically hypo-echoic on B-US and have a strong iso- or hyperenhancement on CEUS, which may help in the differential diagnosis of some unclear masses (e.g., hematoma, abscess) in patients with myeloid neoplasias. Nevertheless, histology is necessary for a reliable diagnosis.

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.

Diagnostic Performance of Point Shear Wave Elastography Using Acoustic Radiation Force Impulse Technology in Peripheral Pulmonary Consolidations: A Feasibility Study.

The aim of the study described here was to evaluate the diagnostic performance of lung ultrasound point shear wave elastography using acoustic radiation force impulse (ARFI) in peripheral pulmonary consolidations (PPCs). A total of 87 patients with PPCs diagnosed from April to December 2020 were included retrospectively in the study. The inclusion criteria were (i) a PPC >1 cm; (ii) valid ARFI measurements; and (iii) confirmation of the diagnosis of a PPC by histocytological examination and/or clinical and radiological follow-up. The presence of pleural effusions and mean ARFI velocities (MAVs) of PPCs were evaluated. To examine the MAV for potential cutoff values between benign and malignant PPCs, a receiver operating characteristic analysis was implemented. In total, 48 of 87 PPCs (55.2%) were accompanied by pleural effusions. Benign PPCs had significantly lower MAVs than malignant PPCs (1.82 ± 0.97 m/s vs. 3.05 ± 0.73 m/s, p < 0.001). Selecting 2.21 m/s as a cutoff value yielded a sensitivity and specificity of 89.7% and 75.9%, respectively, in diagnosing malignant PPCs (area under the curve = 0.852, 95% confidence interval: 0.773-0.931). In summary, ARFI elastography may be an additional non-invasive tool for differentiating benign from malignant PPCs. Furthermore, the feasibility of using ARFI elastography in PPCs associated with pleural effusions was proved. However, there is some degree of overlap between different disease entities, and diagnosis should always take into account the clinical background.

The Value of Lung Ultrasound to Detect the Early Pleural and Pulmonary Pathologies in Nonhospitalized COVID-19-Suspected Cases in a Population With a Low Prevalence of COVID-19 Infection: A Prospective Study in 297 Subjects.

OBJECTIVES: This prospective study aimed to evaluate the value of B-mode lung ultrasound (LUS) for the early diagnosis of coronavirus disease 2019 (COVID-19) infection in nonhospitalized COVID-19 suspected cases in a population with a low prevalence of disease. METHODS: From April 2020 to June 2020, in an ambulatory testing center for COVID-19-suspected cases, 297 subjects were examined by LUS before a nasopharyngeal swab was taken for a reverse transcription polymerase chain reaction (RT-PCR) test. The following LUS findings were defined as pathological ultrasound findings and were analyzed: the presence of 1) pleural effusion, 2) B-lines, 3) fragmented visceral pleura, 4) consolidation, and 5) air bronchogram in the consolidation. The LUS findings were compared with the RT-PCR test results. RESULTS: The result of the RT-PCR test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was positive in 11 and negative in 286 subjects, and the prevalence of COVID-19 infection in the study participants was 3.7%. On LUS, a pathological finding could be detected in 56/297 (18.9%) study participants. The LUS revealed a sensitivity of 27.3%, a specificity of 81.5%, a positive predictive value of 5.4%, a negative predictive value of 96.7%, and a diagnostic accuracy of 79.9% for the identification of COVID-19 infection. CONCLUSIONS: For the identification of COVID-19 infection, LUS is highly sensitive to the patient spectrum and to the prevalence of the disease. Due to the low diagnostic performance in nonhospitalized COVID-19 cases in low-prevalence areas, LUS cannot be considered to be an adequate method for making a diagnosis in this group.