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306
A. N. Sencha et al.
a
b
Fig. 17.4 Metastatic jugular and axillary LNs. CEUS
images. (a) Early arterial phase CEUS demonstrates heterogeneous hyperenhancement of the right jugular LN.
(b) Late arterial phase CEUS depicts the same LN, which
invades the enhanced jugular vein. (c) Homogeneously
enhanced axillary LN in the arterial phase CEUS image.
(d) Poor heterogeneous enhancement of the axillary LNs
17 Lymph Nodes
c
307
d
Fig. 17.4 (continued)
308
A. N. Sencha et al.
a
b
Fig. 17.5 Neck LNs in Hodgkin lymphoma. CEUS images. (a) The uniform dotted enhancement of the increased LN
in the arterial phase. (b) Heterogeneous enhancement in the early venous phase
17 Lymph Nodes
Table 17.1 The values of TIC in the study of patients with lymphoma before and after therapy in groups with full
response and no response to therapy
Responders Non-responders
Before therapy After therapy Before therapy After therapy
AUC 574.5±123.6 244.9±120.8 484.9±67.0 455.5±135.1
ΔAUC −329.5±129.4 −29.4±153.8
PI
ΔPI −5.38±5.8
I 14.4±4.2 7.7±3.0 14.861±6.213 13.1±5.3
ΔI
AUC area under the curve, PI peak intensity
I—change of peak intensity, Δ marks the changes before treatment and after the rst three cycles of chemotherapy
−35.3±3.4 −40.5±5.2 −35.9±3.6 −34.3±2.7
1.6±3.9
6.6±3.5
−1.7±7.5
309
tumor and detains the tumor cells. The status
of a sentinel LN is extremely important
because it determines the tumor stage and
management. The possibility to use CEUS for
the detection of sentinel LN was first reported
in 2004in an animal model [17]. Up to now,
the proposed method was used in many studies
[2, 7, 18–22].
The method is often applied in patients with
breast carcinoma. Subcutaneous administration
of UCA is used.
This technique has high sensitivity in the detection of sentinel LN, but low specicity for its metastatic involvement in patients with breast
carcinoma. Sentinel LN detection rate reaches
71–96%; the sensitivity, specicity, positivepredictive value, negative predictive value, and
accuracy of predicting sentinel LN metastases by
CEUS enhancement patterns account for
98–100%, 49–52%, 43%, 100%, and 65%, respectively [23, 24].
The SonoVue® microbubble suspension is prepared with 2mL of sterile saline. After periareolar local inltration anesthesia, UCA is
administered subcutaneously and intradermally
with several 0.2–0.5mL injections in the periareolar area. After that, the injection area is gently massaged avoiding increased pressure. This
stimulates the spreading of microbubbles to the
lymphatic channels. Microbubble distribution in
the ducts and their accumulation in LN can be
registered with low MI sonography immediately
after UCA injection (Figs. 17.6 and 17.7).
Typically, the time of UCA passage from the
injection site to the axillary LN ranges from 5 to
70s, and UCA remains in the LN for up to 4min.
Enhanced lymph nodes could be detected by
moving the probe along the enhanced lymph
channels. The rst or rst group of enhanced
lymph nodes are considered sentinel LNs.
Massaging the injection site intensies the image
again [21].
UCA accumulation in a LN exhibits various
patterns of contrast enhancement that have the corresponding prognostic value [20]. Heterogeneous
enhancement may indicate metastatic nature,
while uniform accumulation enhancement suggests normal LN.However, the enhancement patterns are not considered for differential diagnosis.
The identication of sentinel LN aims to assist the
targeted biopsy. In the absence of contrast enhancement of the ducts or LNs, another injection may be
given. The sensitivity of this CEUS method in the
detection of sentinel LNs is 92–98% as referred to
intraoperative detection with blue dye [14,
21–25].
CEUS enables effective assessment of the
state of regional lymph drainage in different locations. It facilitates the determination of tumor
dissemination, staging, and management.
310
A. N. Sencha et al.
a
b
Fig. 17.6 CEUS of the regional lymph drainage area
with peritumoral intradermal administration of SonoView
in a patient with breast carcinoma. CEUS images. (a)
UCA collection at the place of injection. (b) A small sentinel LN with irregular enhancement in the axillary area
17 Lymph Nodes
a
311
b
Fig. 17.7 CEUS of the regional lymph drainage area
with peritumoral intradermal administration of SonoView
in a patient with breast carcinoma. (a) Homogeneously
hyperenhanced sentinel LN. (b) Heterogeneously hyperenhanced sentinel LN.Lymph nodes and ducts are marked
with arrows
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A. N. Sencha et al.
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Major Blood Vessels
MunirG.Tukhbatullin , ElenaE.Fomina ,
NatalyaI.Bayazova , andMaratZ.Khasanov
18
Modern ultrasound technologies permit accurate
diagnosis of a wide range of vascular pathologies. However, Doppler imaging has some limitations, which may distort a true hemodynamic
picture.
CEUS lacks many well-known disadvantages
of color Doppler. It enables better delineation of
the intima boundary and high-quality imaging of
the vessel lumen regardless of the scanning angle
and the severity of stenosis. It is also efcient in
the identication of aneurysms and small areas of
dissection.
Abdominal aortic aneurism incidence is 10–40
cases per 100,000 population per year [1]. More
than 85% of aneurysms are asymptomatic. The
traditional US is the rst-line screening method
and an accurate modality for the differential diagnosis of abdominal aortic aneurysm. It has a sensitivity of 95–98%. However, certain limitations
result from the lack of direct signs of the abdominal aortic aneurysm rupture [2–4]. UCAs enable
imaging of the aortic wall and extravasation of
microbubbles beyond the aneurysm [5].
M. G. Tukhbatullin (*) · E. E. Fomina
N. I. Bayazova
Department of Ultrasound Diagnosis, Kazan State
Medical Academy, Kazan, Russian Federation
e-mail: munir.tuhbatullin@tatar.ru
M. Z. Khasanov
Department of Ultrasound Diagnostics, Republican
Clinical Oncological Dispensary of the Ministry of
Healthcare of the Republic of Tatarstan,
Kazan, Russian Federation
CEUS is a simple and non-invasive modality
that permits reliable monitoring of the patients
after stent-graft aortic repair [6, 7]. It aims to
detect endoleaks and other local complications.
Endoleak is the persistent blood ow outside the
lumen of an endoluminal graft but within the
aneurysm sac or adjacent vascular segment being
treated by the device used for endovascular aneurysm repair [8].
There are ve below listed types of endoleaks,
each with different causes and treatment options
(Figs.18.1, 18.2, 18.3, and 18.4):
• Type I endoleak occurs when there is a gap
between the graft and the vessel wall at the
superior or inferior “seal zone,” which allows
blood to ow along the side of the graft into
the aneurysm.
• Type II endoleak results from the increased
pressure within the side branches of the aorta,
such as lumbar, inferior mesenteric, accessory
renal, or other arteries, which force blood to
leak back into the lower-pressure aneurysm
sac.
• Type III endoleak results from a defect or mis-
alignment between the components of the
endograft.
• Type IV endoleak occurs soon due to the
porosity of certain graft materials.
• Type V endoleak, known as endotension, has
no evident cause.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
A. N. Sencha, Y. N. Patrunov (eds.), Contrast-Enhanced Ultrasound,
https://doi.org/10.1007/978-3-030-91764-7_18
315
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M. G. Tukhbatullin et al.
Fig. 18.1 Abdominal aorta after normal endovascular
aortic aneurysm repair. The arterial phase transverse
CEUS image. Two iliac stent-graft segments (arrows)
with regularly enhanced lumen are identied. The aneurism sac has no enhancement
Fig. 18.2 Abdominal aorta after endovascular aortic
aneurysm repair complicated with type Ia proximal
endoleak. The arterial phase transverse CEUS image. The
aortic aneurysm sac is enhanced along with the stent-graft
lumen. Endoleak type Ia due to inadequate proximal seal