The technical part of these Guidelines and Recommendations, produced under the auspices of EFSUMB, provides an introduction to the physical principles and technology on which all forms of current commercially available ultrasound elastography are based. A difference in shear modulus is the common underlying physical mechanism that provides tissue contrast in all elastograms. The relationship between the alternative technologies is considered in terms of the method used to take advantage of this. The practical advantages and disadvantages associated with each of the techniques are described, and guidance is provided on optimisation of scanning technique, image display, image interpretation and some of the known image artefacts. Der technische Teil dieser Leitlinien und Empfehlungen, der unter der Federführung der EFSUMB entstanden ist, enthält eine Einleitung zu allen physikalischen Grundlagen und Methoden der aktuell kommerziell erhältlichen Ultraschall-Elastografie-Technologien. Unterschiede in der Schersteifigkeit sind der wesentliche physikalische Mechanismus, dem der Gewebekontrast in allen Elastogrammen zu Grunde liegt. Die Beziehung zu alternativen Technologien wird und die Vorteile der angewandten Methode herausgearbeitet. Die praktischen Vorteile und Nachteile jeder Technik werden beschrieben und Empfehlungen zur Optimierung der Scantechnik, der Bildqualität und der Bildinterpretation gegeben, ebenso werden einige der bekannten Artefakte dargestellt.

The clinical part of these Guidelines and Recommendations produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology EFSUMB assesses the clinically used applications of all forms of elastography, stressing the evidence from meta-analyses and giving practical advice for their uses and interpretation. Diffuse liver disease forms the largest section, reflecting the wide experience with transient and shear wave elastography . Then follow the breast, thyroid, gastro-intestinal tract, endoscopic elastography, the prostate and the musculo-skeletal system using strain and shear wave elastography as appropriate. The document is intended to form a reference and to guide clinical users in a practical way. Der klinische Teil dieser unter der Schirmherrschaft der EFSUMB erstellten Richtlinien und Empfehlungen beurteilt die klinisch genutzten Anwendungen aller Formen der Elastografie, betont die Evidenz von Meta-Analysen und gibt praktische Hinweise in Bezug auf Einsatz und Interpretation der Elastografie. Die diffusen Lebererkrankungen nehmen den größten Teil ein und spiegeln somit die umfangreiche Erfahrung in der transienten und der ShearWave-Elastografie wider. Es folgen Brust, Schilddrüse, Gastrointestinaltrakt, endoskopische Elastografie, Prostata und Muskel-Skelett-System unter Verwendung von Strain und gegebenenfalls ShearWave-Elastografie. Diese Publikation soll als Empfehlung dienen und klinische Anwender auf praktische Art anleiten.

Context: Asymptomatic sporadic nonfunctioning, well-differentiated pancreatic neuroendocrine tumors (NF-PNETs) are increasingly diagnosed, and their management is controversial because of their overall good but heterogeneous prognosis. Objective: The objective of the study was to assess the natural history of asymptomatic sporadic NF-PNETs smaller than 2 cm in size and the risk-benefit balance of nonoperative management. Experimental Design: From January 2000 to June 2011, 46 patients with proven asymptomatic sporadic NF-PNETs smaller than 2 cm in size were followed up for at least 18 months with serial imaging in tertiary referral centers. Results: Patients were mainly female (65%), with a median age of 60 years. Tumors were mainly located in the pancreatic head (52%), with a median lesion size of 13 mm (range 9–15). After a median follow-up of 34 months (range 24–52) and an average of four (range 3–6) serial imaging sessions, distant or nodal metastases appeared on the imaging in none of the patients. In six patients (13%), a 20% or greater increase in size was observed. Overall median tumor growth was 0.12 mm per year, and neither patients nor tumor characteristics were found to be significant predictors of tumor growth. Overall, eight patients (17%) underwent surgery after a median time from initial evaluation of 41 months (range 27–58); all resected lesions were European Neuroendocrine Tumor Society T stage 1 (n = 7) or 2 (n = 1), grade 1, node negative, with neither vascular nor peripancreatic fat invasion. Conclusions: In selected patients, nonoperative management of asymptomatic sporadic NF-PNETs smaller than 2 cm in size is safe. Larger and prospective multicentric studies with long-term follow-up are now needed to validate this wait-and-see policy.

Autoimmune pancreatitis (AIP) is a particular type of chronic pancreatitis that can be classified into diffuse and focal forms. The aim of this study was to analyze clinical and instrumental features of patients suffering from the diffuse and focal forms of AIP. AIP patients diagnosed between 1995–2008 were studied. A total of 87 AIP patients (54 male and 33 female patients, mean age 43.4±15.3 years) were studied. Focal-type AIP was diagnosed in 63% and diffuse-type in 37%. Association with autoimmune diseases was observed in 53% of cases, the most common being ulcerative colitis (30%). Serum levels of IgG4 exceeded the upper normal limits (135 mg/dl) in 66% of focal AIP and in 27% of diffuse AIP (P=0.006). All patients responded to steroids. At recurrence non-steroid immunosuppressive drugs were successfully used in six patients. Recurrences were observed in 25% of cases, and were more frequent in focal AIP (33%) than in diffuse AIP (12%) (P=0.043), in smokers than in non-smokers (41% vs. 15%; P=0.011), and in patients with pathological serum levels of IgG4 compared to those with normal serum levels (50% vs. 12%; P=0.009). In all, 23% of the patients underwent pancreatic resections. Among patients with focal AIP, recurrences were observed in 30% of operated and in 34% of not operated patients. Focal-type and diffuse-type AIP differ as regards clinical symptoms and signs. Recurrences occur more frequently in focal AIP than in diffuse AIP. The use of non-steroid immunosuppressants may be a therapeutic option in relapsing AIP.

The purpose of this article is to discuss the use of contrast-enhanced ultra-sound (CEUS) in focal liver lesions. Focal liver lesions are usually detected incidentally during abdominal ultrasound. The injection of microbubble ultrasound contrast agents improves the characterization of focal liver lesions that are indeterminate on conventional ultrasound. The use of CEUS is recommended in official guidelines and suggested as a second diagnostic step after ultrasound detection of indeterminate focal liver lesions to immediately establish the diagnosis, especially for benign liver lesions, such as hemangiomas, avoiding further and more expensive examinations.