New trends in ultrasound of hepatosplenic sarcoidosis Sonografische Techniken zur Beurteilung der Sarkoidose von Leber und Milz C. Tana 1, 2 , M. Silingardi 1 , C. F. Dietrich 3 Affiliations 1 Internal Medicine Unit, Guastalla Hospital, AUSL Reggio Emilia, Italy 2 Unit of Internistic Ultrasound, Department of Medicine and Science of Aging, “G. d’ Annunzio” University, Chieti, Italy 3 Innere Medizin 2, Caritas Krankenhaus Bad Mergent- heim, Germany Bibliography DOI http://dx.doi.org/10.1055/ s-0034-1399122 Z Gastroenterol 2015; 53: 283– 284 © Georg Thieme Verlag KG Stuttgart · New York · ISSN 0044-2771 Correspondence Dr. Claudio Tana AUSL Reggio Emilia Via Donatori di Sangue 1 42016 Guastalla Italy claudio.tana@ausl.re.it Sarcoidosis is a chronic inflammatory disease, with several issues unexplained and others not comple- tely understood. It can involve ubiquitously any organ or tissue, leading often to a significant mor- bidity and mortality [1, 2]. The main histopatho- logical finding is represented by non-caseating granulomas, an incomplete degradation of anti- genic stimuli, associated with an exuberant macro- phage, T- and B-cell activity due to prolonged antigenaemia [3]. By definition, the diagnosis of sarcoidosis is achieved with the presence of appro- priate clinical and radiologic thoracic findings, the demonstration of non-caseating granulomas and exclusion of alternative causes [4]. However, symptoms are often nonspecific and radiologic features can be misleading if not inclu- ded in an appropriate context [5]. Sarcoidosis can present with extrapulmonary disease that mani- fests with nonspecific findings on imaging. The problem becomes even more complex because extrathoracic involvement, in particular in the liv- er and spleen, can be isolated without constitu- tional symptoms or systemic disease. It is not so rare, in fact, to find isolated manifestations that can be misdiagnosed with other diseases [6, 7]. For these reasons, the role of imaging in hepatos- plenic sarcoidosis is often reserved for staging and not for diagnostic purposes, by revealing dif- fuse or focal organ involvement and lymphadeno- pathy [8]. However, even though the role of con- ventional imaging such as computed tomography (CT) and magnetic resonance imaging (MRI) has been described widely in the literature [9], there is a lack of information regarding the use of con- trast-enhanced ultrasound (CEUS) [6]. No studies have been designed in patients with sarcoidosis and current data is limited on the description of small cases series; however, we have found re- cently that CEUS has a great potential in the as- sessment of focal lesions in sarcoidosis, in partic- ular those affecting liver and spleen [10]. Hypo and hyperechoic lesions but also isoechoic masses can be clearly highlighted after injecting contrast agent. Hypoechoic nodules of the liver appear as vari- ably arterial enhancing and progressively hy- poenhancing masses in the portal-venous and late phases; also hypoechoic splenic lesions man- ifest as progressive hypoenhancing nodules in both arterial and parenchymal phases. Hyperecoic nodules, both in liver and spleen, are even rarer and no CEUS pattern has been reported so far in the literature; however, we expect sim- ilar features between hypo and hyperechoic no- dules in view of their similar hypodense pattern on CECT. Isoechoic lesions, that are not evident on conventional B-mode US, can be easily re- vealed after injecting contrast agent [10]. The dif- ferent aspect on imaging has already been attrib- uted to a different degree of fibrous tissue in the lesions [11, 12]. Also enlarged lymph nodes can be well assessed. In particular, perihepatic lymphadenopathy shows homogenous enhancement during the arterial phase, suggesting a benign inflammatory pattern [10, 13, 14]. CEUS can overcome several limits of conventional imaging such as CT and MRI in assessing hepatos- plenic sarcoidosis. Ultrasound contrast agents (UCAs) are not nephrotoxic and can be used safely in patients at risk (e. g., those with chronic renal disease); additionally, there is no risk of radiation exposure after UCAs administration. This can be particularly helpful in the follow-up of patients with sarcoidosis under corticosteroid therapy, be- cause examinations can be easily repeated to re- veal any change in contrast enhancement without any biological risk [10]. As already highlighted, however, current evidence derives from case re- ports or small descriptions of cases; we hope that future studies will assess reliability of CEUS in pa- tients with sarcoidosis, by comparing CEUS with other techniques such as CT and MRI, and also with histopathological examinations of affected tissues. The diagnosis of hepatosplenic sarcoidosis repre- sents a challenge for gastroenterologists [15]; an adequate clinical and laboratory evaluation, fol- lowed by a correct imaging approach can provide a successful solution for the diagnosis of this dis- ease. CEUS may be a promising imaging technique in this situation, and we anticipate that CEUS will be considered in future trials aimed at assessing hepatic and splenic localization of sarcoidosis. These studies may radically change the approach to this complex disease. References 01 Valeyre D, Prasse A, Nunes H et al. Sarcoidosis. Lancet 2014; 383 (9923): 1155 – 67 02 Tana C, Giamberardino MA, Di Gioacchino M et al. Im- munopathogenesis of sarcoidosis and risk of malig- nancy: a lost truth? Int J Immunopathol Pharmacol 2013; 26 (2): 305 – 313 03 James DG. A clinicopathological classification of gran- ulomatous disorders. Postgrad Med J 2000; 76 (898): 457 – 465 04 Statement on sarcoidosis. Joint Statement of the American Thoracic Society (ATS), the European Re- spiratory Society (ERS) and the World Association of Sarcoidosis and Other Granulomatous Disorders (WASOG) adopted by the ATS Board of Directors and by the ERS Executive Committee, February 1999. Am J Respir Crit Care Med 1999; 160 (2): 736 – 755 Editorial 283 Tana C et al. New trends in … Z Gastroenterol 2015; 53: 283–284 Downloaded by: IP-Proxy BIBLIOTECA S.MARIA NUOVA, Arcispedale Santa Maria Nuova. Copyrighted material.