Detection of peripheral embolic consolidations using contrast-enhanced ultrasonography in patients with no evidence of pulmonary embolism on computed tomography: A pilot study.

AIM: To investigate the value of B-mode imaging and contrast-enhanced ultrasonography (CEUS) in patients with clinically suspected pulmonary embolism (PE) but no evidence of central PE on CT. METHODS: Between May 2004 and February 2015, we included in this retrospective study 19 patients with a risk profile for PE according to their Wells' score, sonographic patterns of peripheral embolic consolidations (EC) on B-mode-imaging and CEUS (ie, missing or inhomogeneous enhancement of the pleural lesions), and exclusion of central PE by CT within 1 week of CEUS. RESULTS: On B-mode imaging, 19 pleural defects presented as hypoechoic. The shape of EC was round in 2, wedge-shaped in 12, polygonal in 3, and presented as atelectasis in 2 cases. On CEUS, 5 of the defects demonstrated, at the arterial and parenchymal phase, a lack of enhancement, and 14 showed an inhomogeneous (mixed) enhancement with wedge-shaped peripheral areas of no contrast enhancement. A second radiologic evaluation of the CT scans revealed PE in two patients and lesions suspicious for malignancy in two other patients. CONCLUSIONS: Despite the lack of definite confirmation of peripheral and central PE on CT, peripheral pleural consolidations with no or inhomogeneous enhancement on CEUS, in combination with the risk profile for a PE, are highly suggestive of EC. If there is still some doubt, histologic confirmation is important to confirm EC and exclude malignancy. Thus, CEUS may close a potential diagnostic gap of small peripheral PE on CT. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:575-579, 2017.

Contrast-enhanced ultrasound (CEUS) in hepatic lymphoma: retrospective evaluation in 38 cases.

PURPOSE: Description of contrast-enhanced ultrasound (CEUS) patterns of hepatic lymphoma. MATERIALS AND METHODS: Over a period of 6 years and 1 month from January 2006 to January 2012, n = 38 patients with histological or clinically apparent hepatic lymphoma were studied by means of CEUS prior to B-mode imaging. RESULTS: Using B-mode imaging, lesions were hypoechoic in n = 37 (97.4 %) cases, while a focal lymphoma lesion was echo-rich in 1 case (2.6 %). For comparison, with CEUS, a hyperenhanced signal during the arterial phase was observed in n = 9 (23.7 %), an isoenhanced signal in n = 17 (44.7 %) and a hypoenhanced signal in n = 12 (31.6 %) cases. During the portal phase n = 2 (5.3 %) lesions were isoenhanced and n = 36 (94.7 %) were hypoenhanced followed by a hypoenhancement in n = 38 (100 %) cases in the late phase. CONCLUSION: Lymphomas of the liver can cause different contrast accumulation in the arterial phase of CEUS. Furthermore, a clear differentiation from other malignant liver lesions such as metastases is crucial as different contrast accumulation in the arterial phase of CEUS is observed. In the late phase, hepatic lymphomas lead to a hypoenhancement in CEUS, also known as a "wash-out" phenomenon. In conclusion, CEUS is helpful to differentiate hepatic lesions by means of evaluating the malignancy or benignancy. In this regard, the application of CEUS can help to find the right diagnosis. A final discrimination between malignant liver lesions, such as liver lymphomas, metastasis or HCC, remains impossible.

Paclitaxel and simultaneous radiation in the treatment of stage IIIA/B non-small cell lung cancer.

In a clinical phase II trial, escalating doses of paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) were given with concurrent radiation to patients with stage IIIA/B non-small cell lung cancer. Radiotherapy was given in daily doses of 2 Gy, 5 days a week, in weeks 1 through 3 and 6 through 8. Paclitaxel was given on day 1 of weeks 1 through 3 and 6 through 8, at a starting dose level of 50 mg/m2. Subsequent paclitaxel dose levels were 60, 72, 86, and 103 mg/m2. Three to six patients were included at each dose level until intolerable toxicity (World Health Organization grade 3 or 4 leukopenia) occurred in three of six patients. To date, 27 patients have entered the protocol. Hematologic toxicity was mild with no severe myelosuppression up to the 86-mg/m2 dose level. At paclitaxel 103 mg/m2, four of six patients developed grade 3 or 4 leukopenia, and dose escalation was stopped. The maximum tolerated dose was thus determined to be 86 mg/m2. The main clinical toxicity was the occurrence of pulmonary infections (seven patients), one of whom had Pneumocystis carinii infection; the six others had interstitial infections with no pathogen isolated. Mild to moderate esophagitis was seen in five patients. Thus far, of 24 patients evaluable for response, 18 showed decreased tumor size. Four patients achieved major responses (near-complete disappearance of radiologic tumor signs), 11 patients achieved partial remission, and three patients had a minor response. The overall response rate was 75%. In summary, the maximum tolerated dose of paclitaxel in this study has been determined to be 86 mg/m2 weekly. Pulmonary infections represent the major clinical toxicity, and the high response rate merits further clinical evaluation of this regimen.

Paclitaxel and simultaneous radiation in the treatment of stage III A/B non-small cell lung cancer.

In a clinical phase II trial, radiotherapy and escalating doses of paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) were given concurrently to patients with stage IIIA/B non-small cell lung cancer. Radiotherapy was given in daily doses of 2 Gy, 5 days a week, in weeks 1 to 3 and 6 to 8 for a total dose of 56 Gy. Paclitaxel was given in 3-hour infusions on day 1, also in weeks 1 to 3 and 6 to 8. The starting dose level was 50 mg/m2; the subsequent dose levels were 60, 72, 86, and 103 mg/m2. Cohorts of three to six patients were assigned to each dose level until intolerable toxicity (eg, World Health Organization grade 3 or 4 leukopenia) occurred in three of the six patients. Currently, 15 patients have entered the study. Twelve patients have finished the treatment protocol and are evaluable for toxicity and response. Hematologic toxicity was mild, and even at 86 mg/m2, the highest evaluable dose level, no severe myelosuppression was noticed. The main clinical toxicity was the occurrence of pulmonary infections, which were seen in five patients. One of these patients had a Pneumocystis carinii infection, but no pathogens were isolated from the four others with interstitial infections. Mild to moderate esophagitis was seen in five patients. All patients showed a decrease of tumor size. Four patients had a major response with nearly complete disappearance of radiologic tumor signs, five patients had a partial remission, and three patients experienced a minor response. Thus, the overall response rate was 75%. In summary, the maximum tolerated dose of paclitaxel has not yet been achieved, the occurrence of pulmonary infections represents the major clinical toxicity, and the extremely high response rate merits further clinical evaluation of this regimen.

Color Doppler imaging of focal splenic masses.

UNLABELLED: We report the sonographic findings in 43 patients with focal splenic masses. A differential diagnosis of splenic tumors was attempted on the basis of echotexture, size, vascularity and patterns of blood flow within and around tumors on color Doppler sonography. Using the surrounding splenic tissue as an in vivo reference, markedly hypervascular (n = 3), hypervascular (n = 2), isovascular (n = 4), hypovascular (n = 3), and avascular (n = 31) tumors could be differentiated. The final diagnoses were splenic infarction (n = 13), splenic rupture (n = 9), splenic metastasis (n = 7), splenic lymphoma (n = 3), splenic abscess (n = 4), hemangioma (n = 3), splenic cyst (n = 3) and splenoma (n = 1). In 17 cases (40%) color Doppler provides no further information for diagnosis, color Doppler was helpful in 21 patients (49%) and in four (9%) cases, Doppler sonography detects unexpected flow phenomena and was necessary for final diagnosis and treatment. In one patient (2%) sonographic diagnosis was incorrect. CONCLUSION: Characteristic patterns of blood flow were seen in different splenic tumors and can, therefore, aid in the differential diagnosis of focal splenic lesions, and identify patients at risk for serious complications.

Adrenal masses in lung cancer: sonographic diagnosis and follow-up.

Ultrasound has become an important diagnostic modality in the staging of patients with lung cancer. Between 1980 and 1990, 410 patients with histologically proved lung cancer were evaluated. In 44 patients (11%) an adrenal mass was discovered on ultrasound; in 13 patients it was isolated, and in 31 further evidence of abdominal disease was shown. Sonographic follow-up examinations of adrenal masses showed changes of size in all but 2 patients, and were therefore found to be adrenal metastases. In the 2 patients with isolated and stable adrenal disease, fine-needle biopsy revealed adenomas. Adrenal masses in patients with lung cancer are more likely to be metastatic than benign. The existence of neoplastic adrenal disease can be retrospectively confirmed by changes of size during sonographic follow-up examinations in almost all patients. Histologically verification would only appear necessary in stable adrenal disease and in cases with isolated adrenal disease in which prompt diagnosis affects treatment decision.

Carboplatin and simultaneous radiation in the treatment of stage IIIA/B non-small cell lung cancer.

The radiosensitizing properties of carboplatin were investigated in preclinical and clinical studies. In human non-small cell lung cancer (NSCLC) cell lines (EPLC 65 H and LCLC 97 TM1) combined carboplatin and radiation therapy was superior to chemotherapy or radiotherapy alone, indicating the existence of additive effects for both treatment modalities. In a subsequent clinical phase II trial, escalating doses of carboplatin were given concurrently with radiation to patients with stage IIIA/B NSCLC. Radiotherapy was given in daily doses of 2 Gy, 5 days a week, during weeks 1-3 and 6 and 7. Carboplatin was given on day 1 in weeks 1-3 and 6 and 7. The starting dose level was 100 mg/m2, followed by dose escalations to 120, 130, 140, 150, 160, 180, and 200 mg/m2. Five patients were to be treated at each dose level until intolerable toxicity (World Health Organization grade 3 or 4 leukopenia) occurred in 3 of the 5. To date, 34 patients have been entered into the study. Toxicity was mild and, even at the 180-mg/m2 dose level, no severe myelosuppression was observed. Thus, the maximum tolerated dose of carboplatin has not yet been reached. Preliminary analysis of response and survival shows an overall response rate of 53% and a median survival of 10 months. Patients receiving higher carboplatin doses (140-160 mg/m2) survived longer than patients who received lower doses (100-130 mg/m2). These preliminary results indicate that combination carboplatin and radiation therapy is a well-tolerated, active regimen in patients with locally advanced NSCLC. Splitting carboplatin administration may reduce its hematologic toxicity.

Ultrasound of extranodal abdominal lymphoma--a review.

Ultrasound is a valuable method for the detection of abdominal lymph node involvement in malignant lymphoma. In this review the characteristic patterns of organ involvement with lymphoma are described, the features compared with other pathologies and the appearances correlated with histological findings.

Splenic lesions: sonographic patterns, follow-up, differential diagnosis.

This report concerns 172 patients with sonographically diagnosed benign and malignant splenic lesions. A variety of echopatterns was observed, but a differential diagnosis was often impossible without contributory clinical data. Thirteen patients underwent ultrasound-guided fine-needle biopsy for histological confirmation or therapy. In 14 cases splenectomy was performed for treatment or final diagnosis. Twenty-three patients had malignant space-occupying lesions of the spleen. 26 cases presented with normal splenic size, 47 showed splenomegaly of different extent. Lymphoma was the main basic illness in 60 patients. Thirteen cases presented with splenic metastases from other neoplasms. 71 malignant splenic lesions were hypoechoic when compared with normal splenic echotexture. Only two patients exhibited hyperechoic metastases. In three cases a 'halo' sign was seen. In 99 patients benign focal lesions of the spleen were diagnosed. These included splenic infarction (n = 36), dysontogenetic cysts (n = 23), splenic abscesses (n = 7), splenic calcification (n = 13), and hyperechoic lesions (n = 17) most probably representing splenic hemangioma.

Sonography of focal lesions of the spleen.

The sonographic appearances of benign and malignant splenic lesions in 154 patients are illustrated. Sixty-six of the 154 patients had malignant splenic lesions; 55 of these had malignant lymphoma and 11 had splenic metastatic lesions. The lesions were hypoechoic in 64 cases (97%), including all cases of malignant lymphoma, and were hyperechoic in two. Eighty-eight patients had benign splenic lesions; findings included cysts, infarcts, abscesses, hemangiomas, and calcifications.

Determining carboplatin/etoposide dosage in extensive stage small-cell lung cancer (SCLC).

In order to define the maximum tolerance level of combined carboplatin/etoposide dosage, patients with extensive stage small-cell lung cancer (SCLC) were treated with a fixed dose of carboplatin (300 mg/m2 iv on day 1) and escalating doses of etoposide starting with 80 mg/m2 iv on days 1-3. Five patients were given this starting and every following dose level. The daily dose of etoposide was increased in increments of 20 mg/m2 iv until severe myelosuppression occurred in 3 of 5 patients. Leuko- or thrombocytopenia WHO grade 3 or 4 occurred in 0/5 of the patients at the dose levels of 80 and 100 mg/m2, in 1/4 of the patients at the level of 120 mg/m2, in 2/5 of the patients at a level of 140 mg/m2, and 3/5 patients at a level of 160 mg/m2. Thus, increase in dosage was stopped at an etoposide dose of 160 mg/m2. Other side effects were mild and consisted predominantly of nausea and vomiting in 14/25 of the patients. The overall response rate was 40% with a 12% complete remission rate, median survival was 9.3 months and median progression-free survival totalled 4.3 months. These results indicate that combined carboplatin/etoposide is a well tolerated regimen in extensive-stage SCLC, with response rates comparable to those of other standard protocols. Using treatment intervals of 4 weeks the recommended dose of etoposide in combination with 300 mg/m2 carboplatin was identified as 140 mg/m2 iv for 3 consecutive days.

Pleural effusion: an "acoustic window" for sonography of pleural metastases.

We report the sonographic findings in 32 patients with malignant disease associated with pleural effusions diagnosed by chest roentgenograms. No tumor lesions were seen in any case on X-ray films. Thoracic sonography, however, detected previously undocumented metastatic disease with diaphragmatic (N = 19), parietal (N = 8), visceral (N = 2) or combined (N = 3) pleural involvement. Additionally, a distinction could be made between nodular lesions (N = 19), sheet-like tumor masses (N = 10), and combined (N = 3) tumor spread. In all cases thoracentesis was performed. Cytology showed malignant cells in 28 patients. Pleural metastasis was histologically confirmed by ultrasound-guided fine needle biopsy in 2 cases. The present study demonstrates the value of scrutinized thoracic sonography in patients with pleural effusion for the detection of pleural metastases.

Malignant ascites: sonographic signs of peritoneal carcinomatosis.

This study was performed in 65 patients with cytologically proved malignant ascites to describe and classify direct and indirect sonographic signs of peritoneal carcinomatosis. Abdominal sonography revealed tumour-associated abnormalities which account for malignant ascites in 60 cases (92%). This includes visualisation of peritoneal metastases (n = 16, 25%); matting together of bowel loops (17, 26%); distribution of fluid (19, 29%); echoes within the fluid space (3, 5%); omental matting (8, 12%); associated masses (21, 32%); lymphoadenopathy (31, 48%); and hepatic metastases (26, 40%). Sonography enables the physician to demonstrate direct and indirect signs of peritoneal carcinomatosis in almost all tumour patients with ascites and is therefore useful in determining whether the cause of ascites is malignant or benign disease.

Gastrointestinal lymphoma: sonographic findings in 54 patients.

Between 1980 and 1990, 580 patients with known malignant lymphoma were referred for sonography for evaluation of abdominal masses as a part of the initial staging of the disease. In 54 patients, sonography showed different degrees of hypoechoic bowel wall thickening; gastrointestinal lymphoma was confirmed by histologic examination in all of these patients (non-Hodgkin lymphoma in 50, Hodgkin disease in four). Nineteen of the 54 patients had primary gastrointestinal lymphoma; the other 35 had widespread tumor with secondary gastrointestinal involvement. The portions of gastrointestinal tract involved included the stomach (38), small intestine (five), colon (seven), and multiple sites (four). Several sonographic patterns were found: 39 patients had circumferential involvement of the bowel wall, four had bulky tumors, and two had nodular extraluminal spread. Eight patients had segmental infiltration, and one had mucosal involvement. The results of this study indicate that sonography is of value for examining patients with gastrointestinal lymphoma and that several patterns of involvement can be detected.

Sonographic patterns of the affected spleen in malignant lymphoma.

Sonographic examination showed spleen involvement in 43 patients with histological evidence of malignant lymphoma. In 23% of these cases the spleen was of normal size and 77% exhibited variable splenomegaly. Focal lesions could be seen in 27 patients, 16 exhibiting diffuse, small-nodule transformation of the sonographic parenchymal texture. Hodgkin lymphomas caused both focal (7 of 16) and diffuse (9 of 16), splenic lesions. All non-Hodgkin lymphomas of high-grade malignancy exhibited focal lesions, which are larger than 3 cm in diameter in 11 out of 13 patients. In non-Hodgkin lymphomas of low-grade malignancy, focal sites and diffuse destruction of splenic tissue texture were found, lesions of under 3 cm in diameter (11 of 13) being characteristic of this subtype.

Splenic infarction: sonographic patterns, diagnosis, follow-up, and complications.

Forty splenic infarcts in 23 patients were examined with ultrasound (US). At clinical presentation, splenic infarction was associated with severe left upper quadrant pain (n = 10) or diffuse abdominal pain (n = 4) or was asymptomatic (n = 9). In this retrospective study, predominantly wedge-shaped (n = 17) or round (n = 23), irregularly delineated (n = 33) or smooth (n = 7), hypoechoic (n = 40) and anechoic (n = 5) lesions were found at first examination. During follow-up observation, four patients died because of complications unrelated to infarct, and five patients underwent splenectomy as a consequence of US findings. Expanding intralienal liquefaction, increasing subcapsular hemorrhage, free peritoneal blood (even in spleens shown to have an intact surface at sonography), and flow phenomena in the area of infarction demonstrated at B-mode pulsed Doppler US were identified as infarct-related complications associated with the risk of splenic rupture. Despite the high self-healing tendency in splenic infarction, short-term follow-up with US is recommended for early recognition of these possible complications.