Dynamic Contrast Enhanced Ultrasound (DCE-US) is an imaging technique that utilizes microbubble contrast agents in diagnostic ultrasound. The EFSUMB guidelines published in 2004, updated in 2008 and 2011 focused on the use of DCE-US, including essential technical requirements, training, investigational procedures and steps, guidance on image interpretation, established and recommended clinical indications and safety considerations. However the quantification of images acquired with ultrasound contrast agents (UCAs) is not discussed in the guidelines. The purpose of this EFSUMB document is to provide some recommendations and descriptions of the quantification of ultrasound images, technical requirements for analysis of time-intensity curves (TICs), methodology for data analysis, and interpretation of the results.

Contrast-enhanced ultrasound clearly improves the differential diagnosis of hepatic tumors and is very helpful in clinical practice when B-scan or power Doppler morphological criteria are missing.

In a multi-center approach under routine clinical conditions, this prospective study demonstrates CEUS to be of equal rank to the CT-scan in regard to the assessment of tumor differentiation and specification. No statistically significant differences could be established. CEUS should be employed before computed tomography is performed for the differentiation of liver tumors, because radiation exposure and invasive biopsies can be avoided in veritable numbers of cases, when precise clinical evaluation of the findings is implemented.

The value of quantitative analysis of EUS elastography recordings was proven by good reproducibility of the videos, as well as good parameters of the AUROC analysis. (Clinical Trials.gov identifier: CT00909103).

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EUS elastography of mediastinal lymph nodes can be performed reliably. The results are good for a noninvasive technique, but they remain inferior to the success rate of EUS-guided FNAB. The method might occasionally be useful for targeting the most suitable lymph nodes for FNAB.

Ultrasound is the method of choice in the detection and characterization of diffuse and focal organic diseases. For B-mode and colour (power) Doppler ultrasound, besides manual skills, (hands-on) a technical knowledge about ultrasound images is of the upmost importance for the investigator. Contrast enhanced ultrasound (CEUS) has become an important diagnostic tool for hepatic, renal, pancreatic indications and several others due to: (a) an increasing rate of studies resulting in sufficient evidence especially in hepatic indications, (b) a rate of adverse events close to zero (1:10,000 in comparison to iodinated contrast agents from 1-12:100) enabling the application of CEUS in patients with severe renal insufficiency or thyroid gland autonomy, and (c) a reasonable price (depends on the country and influence of the health-care system [reimbursement]) and the dosage used. Mini-doses from 0.1 to 0.4 mL are used depending on the contrast agent and applied indication. Therefore a well founded knowledge concerning the technical aspects of CEUS is important for the investigator to avoid misinterpretation especially when artefacts specific for CEUS occur. Special literature is rare. In the presented article we present pitfalls concerning CEUS. The following aspects are considered and illustrated by images: (i) acoustic power (mechanical index) and other aspects resulting in micro bubble destruction, (ii) the possibility of false positive contrast signals in non-vascularized areas, (iii) attenuation caused by too high contrast agent dose, (iv) influence of the frame rate on the spatial resolution, (v) dealing with deep located lesions, (vi) differences in focus positioning in detection and characterization studies, (vii) advantages and disadvantages of replenishment studies, (viii) reliability of contrast enhanced spectral Doppler measurements.

The fourth part of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Guidelines on Interventional Ultrasound describes general aspects of endoscopic ultrasound-guided diagnostic and therapeutic interventions and assesses the evidence for endoscopic ultrasound-guided sampling. Endoscopic ultrasound combines the most advanced high-resolution ultrasound imaging of lesions within the wall and in the vicinity of the gastrointestinal tract and safe and effective fine needle-based tissue acquisition from these lesions. The guideline addresses the indications, contraindications, techniques, adverse events, training and clinical impact of EUS-guided sampling. Advantages and drawbacks are weighed in comparison with image-guided percutaneous biopsy. Based on the most current evidence, clinical practice recommendations are given for crucial preconditions and steps of EUS-guided sampling as well as for safe performance. Additionally, the guideline deals with the principles and reliability of cytopathological reporting in endoscopic ultrasound-guided sampling (short version; the long version is published online).