[Infection with fasciola hepatica - a case series]. / Fasciola-hepatica-Infektionen in der Schweiz - eine Fallserie.

AIM: Described are the clinical and, especially, the contrast-enhanced ultrasonographic presentation and recovery of four cases of fascioliasis occurring between December 2008 and February 2009. MATERIALS AND METHODS: A detailed history, clinical examination and laboratory investigation were followed by contrast-enhanced ultrasonography of the liver and serological evidence for the presence of antibodies. A final contrast-enhanced ultrasound was performed 6 weeks after treatment with triclabendazole. RESULTS: The patients displayed a variety of symptoms ranging from vasospastic myocardial infarction diagnosed via coronary angiography and a first-time occurrence of migraine as a result of hypereosinophilia to fever with weight loss and tumor-like liver lesions. The contrast-enhanced ultrasonographic hepatic changes in fascioliasis are characterized by segmental arterial hyperemia with emphasis on the liver periphery and subcapsular canalicular sparing corresponding to parenchymal necrosis and hemorrhage. In the later phases areas with inflammatory changes were unmasked due to phlebitis of the small portal vessels and granulomatous parenchymal changes. All four patients were successfully treated with triclabendazole without experiencing any serious side effects. CONCLUSION: Contrast-enhanced ultrasonography is well suited for the diagnosis and monitoring of hepatic fascioliasis.

[Contrast medium sonography of neuroendocrine tumors of the gastroenteropancreatic system]. / Kontrastmittelsonographie neuroendokriner Tumoren des gastroenteropankreatischen Systems.

Ultrasonography is at present the primary diagnostic imaging method in patients with abdominal complaints. The innovations in echo enhancers in the last decade in connection with improved software and hardware have substantially extended the diagnostic spectrum of ultrasonography. Thus contrast-enhanced sonography with pulse inversion technology at low mechanical index allows a continuous evaluation of the perfusion of organs and tumors. Neuroendocrine tumors represent a heterogeneous group of endodermal/epithelial tumors, which are often hypervascularized. The morphology and the perfusion behavior of neuroendocrine tumors should be known because the therapeutic options differ substantially from those of other tumors. Contrast-enhanced sonography has already proven to be a valuable alternative in the diagnosis of neuroendocrine neoplasms and their metastases in relation to the established radiological procedures.

Radiofrequency thermal ablation of hepatic metastases of adrenocortical cancer--a case report and review of the literature.

AIM: Radiofrequency thermal ablation (RFA) has shown promise as a technique for treating solid tumors. This method has been suggested as an alternative to surgery in patients with adrenocortical carcinoma (ACC). MATERIALS AND METHODS: We reviewed the literature, and report the case of a patient with stage 4 ACC who received intraoperative and percutaneous RFA of two liver metastasis according to a standard ablation protocol. RESULTS: Post-interventional imaging in our patient demonstrated that after both interventions, a stellar-like structure of vital tumor tissue had remained within the coagulation necrosis. This was the starting point of a fast and progressive tumor recurrence. We suspect heat-sink effects of blood vessels in the highly vascularized metastasis to cause the tumor recurrence. In literature, there are only a few reports of RFA in ACC patients. In addition, there is no large randomized trial investigating the efficacy of RFA against surgery in those patients. CONCLUSIONS: Presently, RFA in ACC should be restricted to patients in whom surgery is contraindicated. It is necessary that strongly vascularized ACC metastases deserve a modified ablation protocol due to perfusion related cooling effects and to increase the efficacy of RFA.

Neuroendocrine tumors: characterization with contrast-enhanced ultrasonography.

PURPOSE: The aim of this study was to characterize the ultrasonographic features of neuroendocrine tumors (NET) and their metastases with contrast-enhanced ultrasonography (CEUS) and to compare this to clinical data. MATERIALS AND METHODS: During a period of 5 years, 82 patients with 83 histologically proven NET were prospectively examined using conventional US and pulse inversion US with a second generation contrast agent (SonoVue, Contrast Pulse Sequencing) focusing on the arterial (10-20 s p. i.), capillary (20-25 sec p.i.), portal venous (25-120 sec p.i.), and late phases (>120 sec p.i.). 69 patients had metastases in the abdominal tract, including eight patients with poorly differentiated neuroendocrine carcinomas with high-grade behavior. In 31 patients the proliferation index (MIB-1) of the NET was < or = 2%, in 46 patients > 2%, in 6 patients > or = 20%. Thirteen patients had one primary lesion without metastases. RESULTS: In NET of the lung, stomach, and colon we found only hypoechoic or isoechoic liver metastases. NET of the small intestine and pancreas represented hypoechoic, isoechoic, and/or hyperechoic liver lesions, sometimes combined. Insulin producing tumors (6) had hypoechoic metastases. Necrotic areas (25/83) were detected after interferon therapy, embolization, systemic chemotherapy, and radiofrequency ablation of liver metastases, but did not develop after somatostatin receptor radionuclide therapy. In large NET (> 3 cm) with a proliferation index of > 2%, necrotic areas appeared spontaneously. In 93% (77/83) of the cases the NET and their metastases showed an early arterial influx of microbubbles. Rim-like contrast enhancement occurred during the capillary phase in 78% (65/83) of all lesions, and hypervascularization occurred during the arterial phase and at the beginning of the capillary phase in 95% (79/83). The hypervascularized tissue was found in the primary lesions, in liver, lymph node metastases and any kind of abdominal metastases. In liver metastases with a proliferation index >2%, tumor arteries showed a chaotic growth pattern. In 93% (77/83) the NET lesions appeared as dark "defects" at the beginning of the late phase. CONCLUSION: CEUS with CPS demonstrates typical NET imaging characteristics. Differences in imaging features may depend on their primary lesion, size, proliferation marker, and extent of the degenerative changes. In most cases real-time CEUS may replace other imaging techniques.

[Sonographic diagnosis of hilar cholangiocarcinomas by the use of contrast agents]. / Sonografische Diagnostik des hilären cholangiozellulären Karzinoms mittels Echosignalverstärker.

PURPOSE: Imaging of hilar cholangiocarcinomas (Klatskin tumour) is very difficult as these tumours spread along the bile ducts and are hardly distinguishable from the surrounding liver parenchyma. Improved imaging techniques are useful for diagnosis and monitoring of new treatment strategies like photodynamic therapy. In a prospective study, we investigated whether contrast-enhanced sonography is useful in the imaging of Klatskin tumours. MATERIALS AND METHODS: Between 1997 and 2004, 72 patients with suspected Klatskin tumour were admitted to our clinic. 47 patients with histologically confirmed hilar cholangiocarcinomas (Bismuth III/IV) were included in the study and investigated by standard B-mode sonography. Consecutively, patients were investigated by the use of an echo enhancer. 27 patients were investigated by Levovist (power-Doppler sonography, 2nd harmonic imaging, high MI), 20 patients were investigated by Sonovue (CPS, low MI). RESULTS: By use of baseline sonography, visualisation of a tumour and differentiation from normal liver parenchyma was possible in 17 of 47 (36%) patients. After application of contrast agents, tumours showed defects in comparison to the intense flow signal of the surrounding liver tissue during the portalvenous phase and could be discriminated from normal liver tissue allowing determination of tumour size and infiltration of liver parenchyma in all patients (100%). During the arterial phase, 42/47 (89%) of neoplasms showed hypovascularisation compared to surrounding liver tissue, 5/47 (11%) tumours were hypervascularised. During follow-up, metastatic tumour spread was observed in (20/47) 43% of patients, 25/47 (53%) patients developed ascites. CONCLUSION: Contrast agents allow improved imaging of hilar cholangiocarcinomas. The majority of hilar cholangiocarcinomas are hypovascularised.

Sonographic findings in hepatic involvement of hereditary haemorrhagic telangiectasia.

AIM: Hereditary haemorrhagic telangiectasia, or Rendu-Osler-Weber disease, is an autosomal-dominant disorder characterised by angiodysplastic lesions (telangiectases and arteriovenous malformations) which affect many organs including the skin, lungs, gastrointestinal tract, and brain. A broad spectrum of vascular and structural changes have been reported. Our objective was to systematically examine the prevalence of sonographic findings in hepatic involvement in patients with hereditary haemorrhagic telangiectasia (HHT). METHODS: We studied 22 consecutive patients with hereditary haemorrhagic telangiectasia by ultrasonography in combination with colour-Doppler and pulsed wave-Doppler for liver involvement. The clinical diagnosis of HHT was based on the Curaçon criteria. RESULTS: Sixteen of the 22 patients had signs of hepatic involvement including prominent common hepatic artery (14 of 16), dilatation of the intrahepatic part of the hepatic arteries (15 of 16) and intrahepatic AV-shunts (16 of 16). Ectasia of the hepatic vein, fibrotic parenchymal changes, left accessory hepatic artery and focal hepatic lesions were found less frequently. CONCLUSION: Diagnosis of liver involvement in HHT can be made by sonography with colour-Doppler. The main features of this involvement include prominent common hepatic artery, dilatation of the intrahepatic part of the hepatic arteries and intrahepatic AV-shunts.

[Benign or malignant thrombosis of the jugular vein? - Differentiation with colour-Doppler sonography]. / Benigne oder Maligne Jugularvenenthrombose? - Dopplersonographische Unterscheidung.

Thrombosis can lead to physical impairment and cost-intensive investigations. In some cases, a thrombosis is caused by infiltration of an adjacent tumour. It is therefore important to differentiate between a benign or malignant thrombosis. We report the case of a woman with a malignant thrombosis of the jugular vein. She was hospitalised for suspected malignant disease of unknown origin. Her family doctor had made the diagnosis of a "partially organised thrombosis". At sonography, vessels with an arterial blood flow were detected in the thrombus. A carcinoma of the thyroid gland was therefore suspected and confirmed by histology. This case report demonstrates that the differentiation between a benign and malignant thrombosis is possible with colour-Doppler sonography.

Perforation of a pancreatic pseudocyst induced by abdominal sonography.

A fifty-year-old man complained of abdominal pain, nausea, loss of appetite, postprandial vomiting and loss of weight. Abdominal sonography revealed a chronic calcifying pancreatitis with a tubular stenosis of the common bile duct, dilatation of the pancreatic duct and multiple pancreatic duct stones. Distal of the pylorus there was an intramural pseudocyst, which had led to the obstruction of the duodenal lumen. Shortly after the ultrasound examination abdominal pain increased. In addition, an elevation of serum lipase levels was noted, but reclined rapidly the next day and was normalized a few days later. The patient was well the next morning, the symptoms of gastric retention disappeared and he had a good appetite. A CT of the abdomen two days later showed the chronic pancreatitis but could not confirm the pseudocyst and a subsequent repeat sonography revealed only a remnant of the pseudocyst. In conclusion it can be assumed that the intramural pseudocyst ruptured when pressure was applied with the ultrasound transducer to displace interfering colonic gas. Although it cannot be advised as a treatment measure for a pseudocyst, regression of a pseudocyst due to emptying into the gastrointestinal tract has to be expected.

Differentiation of a pancreatic metastasis of a renal cell carcinoma from a primary pancreatic carcinoma by echo-enhanced power Doppler sonography.

In a 70-year-old patient who had been treated for a renal cell carcinoma, a pancreatic mass was detected on CT scan. To differentiate a pancreatic metastasis of the renal cell carcinoma from a pancreatic carcinoma, an echo-enhanced power Doppler sonography was performed. The pancreatic mass demonstrated a strong echo enhancement, proving its hypervascularization. This behaviour favoured the diagnosis of a pancreatic metastasis of the renal cell carcinoma which was confirmed by histology. The principles and the role of echo-enhanced power Doppler sonography in the differential diagnosis between a primary pancreatic carcinoma and a metastasis of a renal carcinoma in the pancreas are discussed. We conclude that this technique can provide an important contribution to the diagnosis in this special instance. However, histology is the standard in the differential diagnosis of pancreatic tumours.

High-resolution ultrasound in combination with colour-Doppler sonography for preoperative localization of parathyroid adenomas in patients with primary hyperparathyroidism.

BACKGROUND AND AIMS: Experienced surgeons have the highest sensitivity in the localization of parathyroid adenomas in patients with primary hyperparathyroidism. Correct preoperative localization, however, allows unilateral neck exploration with subsequently reduced operative time and complication rate. In this prospective study, we investigated the accuracy of preoperative high-resolution ultrasound in combination with colour-Doppler sonography for the detection of parathyroid lesions. SUBJECTS/METHODS: Ninety-eight patients (mean age 59.1 years, range 15-86) who referred to our department with symptomatic primary hyperparathyroidism were included in the study from January 1998 to June 2002. Sonography was performed by experienced examiners. The exact diagnosis was based on surgical findings and histology in all patients. RESULTS: The overall sensitivity for the sonographical localization of the adenomas on the correct side of the neck was 86 %. Twenty-three percent of the adenomas located on the cranial margin of the thyroid gland were diagnosed correctly, as were 92 % of the lesions located caudally (p = 0.0001). The detection of feeding vessels was possible by colour-Doppler sonography in 60 % of the cases. The diagnosis was correct for 93 % of these suspected adenomas. No vessels were detected in the remaining lesions, and only 39 % of these tumours were diagnosed correctly (p = 0.0001). CONCLUSIONS: High-resolution ultrasonography by experienced examiners is a highly sensitive procedure for the preoperative diagnosis of parathyroid adenomas in patients with primary hyperparathyroidism. With this method, a unilateral neck exploration is sufficient in about 90 % of the patients. Additionally, detection of feeding vessels by colour-Doppler sonography is an important indication of a parathyroid lesion. Nonetheless, the experienced surgeon remains the standard of reference.

Differentiation of neuroendocrine tumors from other pancreatic lesions by echo-enhanced power Doppler sonography and somatostatin receptor scintigraphy.

BACKGROUND AND AIMS: Echo-enhanced power Doppler sonography is a noninvasive procedure that has been increasingly used for the differential diagnosis of pancreatic tumors. However, to our knowledge, the diagnostic accuracy of this procedure in comparison with somatostatin receptor scintigraphy for the differentiation of neuroendocrine lesions from other pancreatic tumors has never been investigated in a prospective, controlled study. SUBJECTS AND METHODS: One hundred thirty-seven patients were included in the study; the patients were selected from 190 consecutive patients (mean age, 59.8 years; range, 16-85 years) who presented to our department from January 1998 through June 2001 with suspicion of a pancreatic tumor. An experienced examiner who was unaware of the patients' clinical diagnoses performed sonography. Twenty-nine patients with sonographically and/or clinically suspected neuroendocrine tumors were investigated additionally by somatostatin receptor scintigraphy. The exact diagnosis was based upon histologic evidence from biopsy examination (surgical and transabdominal fine-needle biopsy) or a follow-up of at least 18 months. RESULTS: The sensitivity of echo-enhanced power Doppler sonography for diagnosing a neuroendocrine pancreatic tumor was 94%, and its specificity was 96%. The corresponding values for somatostatin receptor scintigraphy were 54% and 81%, respectively. CONCLUSIONS: Echo-enhanced power Doppler sonography has high sensitivity and high specificity for the differentiation of neuroendocrine lesions from other pancreatic tumors. However, histologic evidence is the standard of reference for the differential diagnosis of pancreatic tumors.

Differentiation of pancreatic tumours by conventional ultrasound, unenhanced and echo-enhanced power Doppler sonography.

BACKGROUND: Echo-enhanced power Doppler sonography (power Doppler sonography after injection of a contrast agent) is a non-invasive and increasingly used procedure for differentiating between pancreatic tumours. However, the diagnostic accuracy of this method compared to conventional ultrasound or unenhanced power Doppler sonography has never been investigated in a large prospective controlled study. METHODS: 137 patients were included in the study, selected from 190 consecutive patients with a mean age of 60 years (range 16-85) who presented at our department in the period January 1998 through June 2001 with clinical suspicion of a pancreatic tumour. Sonography was performed by an experienced examiner blind to the patients' clinical diagnoses. The exact diagnosis was based on histological evidence from biopsy examination (surgical and fine needle biopsy) or on a follow-up of at least 18 months. RESULTS: Of the 137 patients, 47 had pancreatic cancer; 41 had masses associated with pancreatitis; 17 had neuroendocrine tumours; 12 had cystic lesions of the pancreas; and 10 had other pancreatic diseases. A normal pancreas was found in 10 patients. The sensitivity of echo-enhanced power Doppler sonography with respect to diagnosing pancreatic carcinoma was 87% and its specificity 94%. The corresponding values for chronic pancreatitis were 85% and 99%, respectively. CONCLUSIONS: Echo-enhanced power Doppler sonography has a high sensitivity and specificity in the differential diagnosis of pancreatic tumours. However, histology is the standard of reference.

[Contrast behaviour of a angiomyolipoma of the liver at echo-enhanced power-Doppler sonography]. / Das Kontrastverhalten des Leberangiomyolipoms in der echosignalverstärkten Power-Dopplersonographie.

Angiomyolipomas of the liver are rare tumours. Differentiation from other liver lesions using imaging techniques is difficult. This is the first report describing the contrast behaviour of an angiomyolipoma of the liver with echo-enhanced power-Doppler sonography. A rapid signal enhancement of the arteries within the tumour and an immediate drainage of the blood into the liver veins was demonstrated. Furthermore, spectrums similar to av-fistulas could be detected. Portal venous blood flow, irregular calibre of the vessels or chaotic vascular patterns could not be found.

[Evaluation of Doppler sonographic criteria for the differentiation of hepatocellular carcinomas and regenerative nodules in patients with liver cirrhosis]. / Evaluierung dopplersonographischer Kriterien zur Differenzialdiagnostik von hepatozellulären Karzinomen und Regeneratknoten bei Leberzirrhose.

AIM: In order to improve the differentiation between hepatocellular carcinomas and regenerative nodules in patients with liver cirrhosis, Doppler-sonographic criteria for the tumours were evaluated. METHOD: Patients with histologically proven hepatocellular carcinoma (n = 35) and regenerative nodules (n = 10) were investigated by B-mode sonography as well as fundamental and echo-enhanced power-Doppler sonography focusing on specific properties of the tumours. The results were correlated to the histological findings. RESULTS: Hepatocellular carcinomas and regenerative nodules showed a different contrast behaviour with echo-enhanced power-Doppler sonography. The following features of hepatocellular carcinomas were frequently found: peritumoural signal detection in the early arterial phase, chaotic and centripetal contrast enhancement in the arterial phase, hypervascularization in the capillary phase, and loss of portalvenous blood flow. CONCLUSION: Hepatocellular carcinomas and regenerative nodules display different vascularization patterns in the echo-enhanced power-Doppler sonography. These characteristics can be useful for their differential diagnosis.

[Differential diagnosis of frequent pancreatic tumours with echo-enhanced power-Doppler sonography - presentation of case reports]. / Fallbeispiele zur Erläuterung der Differenzialdiagnostik von häufigen Pankreastumoren mit der echosignalverstärkten Power-Doppler-Sonographie.

UNLABELLED: The echo-enhanced Power-Doppler sonography is useful for the differential diagnosis of pancreatic tumours. Tumour criteria for the differentiation of pancreatic tumours with this procedure are explained using selected cases in the present publication. Ductal carcinomas are often hypovascularised compared with the surrounding tissue. On the other hand, neuroendocrine tumours are hypervascularised lesions. Tumours associated with pancreatitis have a different vascularisation pattern depending on inflammation and necrosis. Cystadenomas frequently show many vessels along the fibrotic strands. CONCLUSIONS: Pancreatic tumours have different vascularisation patterns in the echo-enhanced Power-Doppler sonography. These characteristics can be used for the differential diagnosis.

Non-invasive evaluation of activity in inflammatory bowel disease by power Doppler sonography.

BACKGROUND: To study the vascularization in the diseased bowel wall by power Doppler sonography in patients with inflammatory bowel disease. PATIENTS AND METHODS: The diseased bowel wall was investigated in 99 patients with inflammatory bowel disease (60 patients with Crohn's disease and 39 patients with ulcerative colitis) either with active disease or in remission by B-mode and power Doppler sonography. Disease activity was determined by clinical indices. Twenty healthy age and sex matched individuals served as controls. RESULTS: Bowel wall was thickened in active Crohn's disease (mean 7 mm, range 4-14) and ulcerative colitis (mean 5 mm, range 2-15) as compared to healthy controls (mean 2 mm, range 1-3), p < 0.001. In contrast to healthy controls blood vessels were detected in the bowel wall in 100 % of patients with active Crohn's disease and 91 % with active ulcerative colitis. Vascularization was significant decreased in patients with quiescent versus active disease in ulcerative colitis (p < 0.05), while in Crohn's disease there was no significance between active and remission phase. CONCLUSIONS: Thickened and hypervascularized bowel wall are characteristic findings in inflammatory bowel disease. A combination of B-mode and power Doppler sonography offers an additional noninvasive procedure for the determination of activity in patients with inflammatory bowel disease.

[Pancreatic metastases of renal cell carcinomas - evaluation of the contrast behavior at echo-enhanced power-Doppler sonography in comparison to primary pancreatic tumors]. / Nierenzellkarzinom-Metastasen des Pankreas - Evaluierung ihres Kontrastverhaltens in der echosignalverstärkten Power-Doppler-Sonographie im Vergleich mit primären Pankreastumoren.

BACKGROUND: Renal cell carcinomas are the most common primary tumors leading to pancreatic metastases. The differentiation of metastases from primary pancreatic tumors is important for the prognosis. Echo-enhanced power-Doppler sonography may be used for the differential diagnosis of tumors. In this study, the contrast behavior of metastases of renal cell carcinomas was evaluated in comparison to primary pancreatic tumors. PATIENTS AND METHODS: Each 5 patients with pancreatic metastases of a renal cell carcinoma, a ductal carcinoma, a neuroendocrine tumor and a pancreatitis-associated mass were investigated by B-mode sonography, fundamental and echo-enhanced power-Doppler sonography. RESULTS: Similar to neuroendocrine tumors, metastases of renal cell carcinomas were found to be hypervascularized. In contrast, ductal carcinomas are hypovascularized compared to the surrounding tissue. Tumors associated with pancreatitis show different vascularization pattern depending on inflammation and necrosis. CONCLUSIONS: Metastases of renal cell carcinomas and ductal carcinomas show different vascularization pattern at echo-enhanced power-Doppler sonography. Renal cell metastases and neuroendocrine tumors have similar contrast behaviors, therefore, clinical symptoms should be referred for their differentiation. However, histology is the standard of reference for the differential diagnosis of pancreatic tumors.