Corinna Trenker

Contrast-enhanced ultrasound of embolic consolidations in patients with pulmonary embolism: A pilot study

To analyze and describe the contrast‐enhanced ultrasound (CEUS) patterns of peripheral lung lesions in patients with pulmonary embolism (PE) confirmed on CT angiography or lung scintigraphy.

Diagnostic accuracy and interobserver agreement of contrast-enhanced ultrasound in the evaluation of residual lesions after treatment for malignant lymphoma and testicular cancer: a retrospective pilot study in 52 patients

Abstract Value of contrast-enhanced-ultrasound (CEUS) in the evaluation of residual lesions (RL) after therapy in patients with malignant lymphomas (ML) and testicular cancer (TC) with regard to tumor activity. From May 2004-October 2010, in n = 52 patients with ML (n = 34) or TC (n = 18) and RL, B-mode-imaging and CEUS of the RL was performed. In CEUS, differentiation was made between high-enhancement (HE), low-(LE) or no-enhancement (NE) of the RL after therapy. Data were retrospectively evaluated. A positive test result (HE) was found in n = 13 (25%); a negative test result (LE/NE) in n = 39 (75%) patients. Sensitivity was 72.7%, specificity 87.8%, positive likelihood-ratio 5.96, negative likelihood-ratio 0.31. In the subgroup of ML a sensitivity of 80% and a specificity of 86.2% was reached. Active residual disease in ML and TC is associated with a marked enhancement, so CEUS might be helpful in the evaluation of RL, especially to exclude residual disease.

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

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.

71-Year-Old Patient with Chronic Lymphocytic Leukemia (CLL) and Hypoechoic Nodular Spleen and Liver Lesions with Fatal Outcome: Presentation of Mucormycosis in B-Mode Imaging and Contrast-Enhanced Ultrasound (CEUS)

Mucormycosis is a fungal infection that can potentially manifest in any organ system. It mainly affects immunocompromised patients with diabetes mellitus type II or malignant hematologic diseases, especially after stem cell transplantation 1 2. In a study of 929 patients facing zygomycosis, infestation of the sinus cavities (39%) was observed most frequently, followed by pulmonary (24%) and cutaneous manifestations (19%) 1. However, mucormycosis of the liver and spleen is rare and has been documented only in several case reports 3. Contrast-enhanced ultrasound (CEUS) is an established and important method for the diagnosis of focal liver lesions. The first guidelines for CEUS of the liver were published in 2004, followed by updates in 2008 and 2012 4. CEUS imaging of mucormycosis has not been described in the literature. To our knowledge, this case report describes hepatic and splenic mucormycosis using CEUS for the first time.

Spontaneous and Traumatic Splenic Rupture: Retrospective Clinical, B-Mode and CEUS Analysis in 62 Patients

Introduction Both B-mode ultrasound and contrast-enhanced ultrasound (CEUS) are well established procedures when diagnosing traumatic splenic ruptures (TSR). To date, there are no data about CEUS patterns in spontaneous splenic ruptures (SSR). It remains unknown whether TSR and SSR differ with respect to clinical characteristics, B-mode and CEUS characteristics. Patients and Methods Between 12/2003 and 2/2010, n=33 SSRs and n=29 TSRs were diagnosed in a tertiary referral center. All patients were examined with B-mode and CEUS, and clinical data and the outcome were retrospectively analyzed. Results Patients with SSR were significantly older than patients with TSR (62 years vs. 44 years; p=0.01). The 4-week mortality was significantly higher in SSR than in TSR (36% vs. 0%; p=0.001). No differences between the grading of TSR and SSR could be shown in B-mode or in CEUS. Notably, CEUS was significantly superior to B-mode with respect to the grading of splenic ruptures (p=0.01). Therefore, therapeutic management was influenced by CEUS. Conclusion There are differences between SSR and TSR, especially concerning clinical data (age, course of disease and mortality). Regarding the sonographic pattern, SSR and TSR show identical grading. When splenic rupture is suspected, CEUS should always be performed to identify patients at risk who require interventional procedures.

Vascularization of Primary, Peripheral Lung Carcinoma in CEUS – A Retrospective Study (n = 89 Patients)

PURPOSE  To describe the vascularization of peripheral lung carcinoma in CEUS and to compare with B-mode ultrasound (US) and clinical data. MATERIALS AND METHODS  From April 2004 until September 2015, n = 89 patients with peripheral lung carcinoma were investigated by B-mode US and CEUS. The extent (EE: hypoechoic, hyperechoic), homogeneity (HE: homogeneous, inhomogeneous) and time of enhancement (TE) have been defined. Early pulmonary-arterial enhancement (PA) before contrast floating to the thoracic wall was differentiated from simultaneous or delayed bronchial-arterial enhancement (BA). CEUS parameters were compared by B-mode US and histology. RESULTS  n = 25 patients had early PA enhancement (TE: 8 ± 3.7 s), and n = 64 (72 %) had simultaneous/delayed BA enhancement (TE: 17.6 ± 6.2 s) (p < 0.001). PA enhancement (EE/HE) was hyperechoic (n = 11/25), homogeneous (n = 11/25) and showed an air bronchogram more often (n = 11/17, p < 0.001). BA enhancement (EE/HE) was frequently hypoechoic (n = 34/64) and inhomogeneous (n = 54/64). BA enhancement was associated with necrosis (n = 36/42, p = 0.009). PA and BA enhancement distributed to different histologies: n = 42 adenocarcinomas (18 PA, 24 BA), n = 30 squamous cell carcinomas (4 PA, 26 BA), n = 13 other types of NSCLC (3 PA, 10 BA), and n = 4 SCLC (0 PA, 4 BA) (p = 0.016). CONCLUSION  The vascularization of peripheral lung carcinomas is heterogeneous and is influenced by histology. In this study, lung carcinomas are predominantly supplied by bronchial arteries, whereas a part of adenocarcinomas and non-adenocarcinomas show PA enhancement.

Clinical diagnosis of veno-occlusive disease using contrast enhanced ultrasound

Veno-occlusive disease (VOD), also known as hepatic sinusoidal obstruction syndrome (SOS), defines a disease based on an incomplete obstruction of sinusoids and venules with the development of portal hypertension. VOD/ SOS is a severe disease and often represents a complication of allogeneic stem cell transplantation. The mortality is high (80 %) [1, 2]. The pathogenesis is not fully understood. Radiotherapy or high-dose chemotherapy is presumed to be the cause [2]. Clinically, the disease is characterized by weight gain, hepatomegaly with epigastric pain, ascites, and an increase of serum bilirubin [1, 2]. Acute renal failure may also occur[1, 2]. Two research groups (Seattle and Baltimore) have described generally accepted diagnostic criteria [1]. However, diagnosis and the decision to initiate treatment are mainly clinical based. Gold standard in the diagnosis is the histological evaluation by means of liver biopsy, which cannot be carried out in everyday clinical practice if the patient’s general condition is poor due to impaired coagulation after allogeneic stem cell transplantation [3]. In addition, biopsy and histological evaluation is time consuming which may cause treatment delay. Contrast enhanced ultrasound (CEUS) is an established method for detection and characterization of focal liver lesions [4]. CEUS has been also used to diagnose liver vein thrombosis, and has proven to be of value for the differential diagnosis of appositional and neoplastic portal vein thrombosis. So far, CEUS has not been used in the diagnosis of VOD/SOS. The following case describes for the first time this pathologic hepatic contrast enhancement as an expression of a pathological hepatic vascularization in a patient with the clinical diagnosis of a VOD. On day 16 after allogeneic stem cell transplantation, a 22-year-old male patient with acute lymphatic leukemia (ALL) presented an increase in transaminases (ALT max 97 U/I), cholestasis parameters (total bilirubin 4.3 mg/dl), restricted coagulation (Quick 74%), and a significant weight gain of 10 kg was observed. Previously a myeloablativeconditioning therapy with 12 Gy total body irradiation, cyclophosphamide, and antithymocyte globulin (ATG) was performed. During therapy, prophylactic continuous administration of heparin (400 IU/h intravenously) was performed to reduce the risk of VOD. In B-mode imaging hepatomegaly, perihepatic ascites, splenomegaly (16 × 6 cm), gallbladder edema, and pleural effusions were detected. The portal vein presented a pulsatile flow profile with reduced flow velocity (Vmax 16 cm/s, Vmin 4 cm/s, Vmean 10 cm/s). CEUS provides much more information than the sole B-mode ultrasound regarding vascularization. Without histological examination, the VOD is an exclusion diagnosis. Therefore, we performed contrast enhanced ultrasound as a further diagnostic tool because of unclear hepatopathy. CEUS presented a regular arterial and portal venous contrast medium inflow but without almost no contrast enhancement in the portal venous and parenchymal phase compared to the enhancement of the spleen as an “in vivo reference” (Fig. 1a–f). As VOD/SOS was suspected, therapy with defibrotides was started. Clinical and laboratory values improved under treatment. The CDS findings improved over the following 14 days and normalized within 6 months with a normal monophasic portal venous flow profile (21 cm/s) but still a reduced parenchymal contrast enhancement of the liver parenchyma compared to the spleen (Fig. 2a–f). At a 6 month follow-up, a complete normalization of all examined parameters was observed, in particular a normal portal venous flow and * C. Trenker Trenker@med.uni-marburg.de

Presentation of Gallbladder Chloroma in B-Mode Imaging and Contrast-Enhanced Ultrasound (CEUS) in a Patient with Acute Myelomonocytic Leukemia (AML M5)

Chloromas (myeloid sarcoma) are solid tumors consisting of primitive myeloid precursors and have been described in acute myeloid leukemia (AML) and myeloproliferative disorders (Aznab, Mozaffar; Kamalian, Naser; Beiki, Omid et al., Int J Hematol Oncol Stem Cell Res 2015; 9 (1), S. 50–54). In AML, they are observed in 3-8 % of all cases, while the frequency varies (J. C.; Edenfield, W. J.; Shields, D. J. et al., Extramedullary myeloid cell tumors in acute nonlymphocytic leukemia: a clinical review. In: J Clin Oncol 1995, 13 (7), S. 1800–1816). Chloromas can be observed at diagnosis, precede the diagnosis, occur during the course of the disease or manifest as a relapse of the AML (Aznab, Mozaffar; Kamalian, Naser; Beiki, Omid et al., Int J Hematol Oncol Stem Cell Res 2015; 9 (1), S. 50–54). They can affect every organ system, with infiltration of bone, skin, soft tissues and lymph nodes being observed most frequently (Aznab, Mozaffar; Kamalian, Naser; Beiki, Omid et al., Int J Hematol Oncol Stem Cell Res 2015; 9 (1), S. 50–54), J. C.; Edenfield, W. J.; Shields, D. J. et al., Extramedullary myeloid cell tumors in acute nonlymphocytic leukemia: a clinical review. In: J Clin Oncol 1995, 13 (7), S. 1800–1816). Single case reports describe chloromas of the gallbladder and the bile ducts (Azin, Arash; Racz, Jennifer M.; Carolina Jimenez, M. et al. Int J Surg Case Rep 2014;5 (6), S. 302–305). In summary, we present the first description of contrast-enhanced ultrasound (CEUS) patterns of a histologically confirmed gallbladder chloroma.

Mesenteric Masses on 2D Mode and Contrast-Enhanced Ultrasound: A Retrospective Study in 69 Patients

PURPOSE  Detection of mesenteric masses (MM) by 2 D ultrasound often causes a diagnostic dilemma, and histological confirmation is required for definite diagnosis. The value of contrast-enhanced ultrasound (CEUS) for the diagnosis of MMs has not been investigated before. Here, we retrospectively evaluate 2D-mode and CEUS patterns of 69 patients with histologically confirmed MMs. MATERIALS AND METHODS  Between January 2006 and January 2016, n = 69 patients were included in the study. Histopathological data, clinical data, 2D-mode ultrasound and CEUS enhancement were retrospectively analyzed. RESULTS  More than half of the MMs (n = 47/69, 68 %) revealed a malignant histology. The size of the MM, inflammation markers and clinical symptoms did not correlate with the histological outcome. 2 D mode revealed n = 46 (67 %) lesions as hypoechoic, n = 14 (20 %) as hyperechoic, and n = 9 (13 %) with a complex echo pattern. Hypoechogenicity and complex echo patterns as well as regular borders of MMs were significantly associated with malignancy (p < 0.05). On CEUS, malignant MMs showed arterial hyperenhancement (n = 11/47, 23 %), isoenhancement (n = 25/47, 52 %) and hypoenhancement (n = 7/47, 15 %). The majority of malignant MMs (n = 42/47, 89 %) revealed parenchymal hypoenhancement. Benign masses revealed arterial hyperenhancement in n = 1/22 (5 %), isoenhancement in n = 8/22 (36 %), and hypoenhancement in n = 10/22 (45 %). The majority of lesions showed parenchymal hypoenhancement (n = 19/22, 86 %). CONCLUSION  Hypoechogenicity and complex echogenicity in 2 D mode, irregular borders, and parenchymal wash-out were more often associated with malignancy. However, CEUS did not help to subclassify malignant MMs according to their histological entity.

Atypische Form der akuten Cholezystitis bei einem Patient mit akuter myeloischer Leukämie (AML): Darstellung von Chloromen der Gallenblase in der B-Bild- und Kontrastmittelunterstützen Sonografie (CEUS)

Anamnese und klinischer Befund: Ein 64-jahriger Patient wurde stationar zur Konsolidierungstherapie bei akuter myeloischer Leukamie (AML) M5 vorstellig. Im Knochenmark zeigten sich diesem Zeitpunkt keine Blasten. Wahrend des stationaren Verlaufes fielen laborchemisch steigende Bilirubinwerte auf. Untersuchungen: In der Abdomensonografie zeigte sich eine Cholestase der intra- und extrahepatischen Gallenwege. Die Gallenblase stellte sich B-bildsonographisch gros, wandbetont mit echogenem Sludge und kleinen Noduli an der Gallenblasenwand dar. In der Kontrastmittelunterstutzen Sonografie (CEUS) zeigten sich Kontrastierungen der Noduli in der Gallenblasenwand, sowie eine partielle Kontrastierung des im Gallenblasenlumen befindenden Sludges. Es wurde der Verdacht auf einen malignen Prozess der Gallenblase geausert. Therapie, Diagnose, Verlauf: In einer anschliesend durchgefuhrten ERCP war die Sondierung des Ductus choledochus auf Grund eines derben Wiederstandes nicht moglich, sodass ein offenes operativen Verfahren mittels Cholezystektomie und externer Gallendrainage angestrebt wurde. Im histopathologischen Untersuchungsbefund zeigte sich eine Infiltration der Gallenblasenwand durch die bekannte AML M5, im Sinne von Chloromen. Diskussion/Schlussfolgerung: Chlorome der Gallenblase oder Gallenwegen sind eine mogliche Differenzialdiagnose zur Cholezystitis bei Patienten mit maligner hamatologischer Grunderkrankung und ungeklarter Cholestase. In der CEUS konnen sich Chlorome der Gallenblase durch eine nodulare Kontrastmittelanreicherung in der Wand und eine Kontrastierung von Sludge im Gallenblasenlumen darstellen.