Multiparametric ultrasound (MPUS) combines B-mode, Doppler techniques, microvascular imaging, contrast-enhanced ultrasound (CEUS), and elastography, thereby enhancing diagnostic precision across a wide spectrum of scrotal diseases. Developed under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), these guidelines provide evidence-based recommendations for the clinical use of MPUS in scrotal imaging. Based on the framework of the Oxford Centre for Evidence-Based Medicine, this document outlines the diagnostic value of MPUS in acute scrotal pain, trauma, infertility, focal and extratesticular lesions, cryptorchidism, and testicular incidentalomas. The recommendations highlight CEUS as the reference method for vascular assessment and elastography as a complementary tool for tissue characterization. These guidelines aim to standardize MPUS practice and promote its integration in routine scrotal imaging.

Background:Imaging during pregnancy presents unique challenges. Computed tomography (CT) is generally avoided due to fetal radiation exposure, and magnetic resonance imaging (MRI) may be limited by concerns regarding gadolinium-based contrast agents. As a result, ultrasound (US) remains the primary imaging tool during pregnancy. Contrast-enhanced ultrasound (CEUS) expands the diagnostic capabilities of conventional US by providing real-time vascular information comparable to contrast-enhanced CT or MRI. Importantly, microbubble contrast agents used in CEUS do not cross the placenta and have shown no fetal harm in clinical studies. Nevertheless, CEUS remains an off-label technique during pregnancy, underscoring the need for a comprehensive review of the available literature to assess its safety and clinical applications during pregnancy. Method:This review summarizes the current evidence up to 2025 on the use of CEUS in pregnancy and highlights its clinical value with respect to evaluating acute and chronic maternal conditions - including oncologic, vascular, infectious, inflammatory, and other organ-specific pathologies - illustrated through representative case examples. Clinical studies, case reports, and international guidelines were analyzed with a focus on safety and diagnostic performance. Conclusion:Although still off-label, CEUS demonstrates an excellent safety profile and high diagnostic utility when clinically indicated in pregnancy. No maternal, fetal, or neonatal adverse effects have been reported, and no placental transfer of microbubbles has been demonstrated. CEUS enables high-resolution assessment of abdominal organs, vascular pathologies, and inflammatory or infectious changes, reducing the need for ionizing or gadolinium-based imaging. It represents a safe, effective, and radiation-free diagnostic alternative when conventional imaging is limited. Key Points:· CEUS expands diagnostic ultrasound without radiation exposure.. · CEUS is a safe alternative to CT or MRI.. · Microbubbles remain intravascular and do not cross the placenta.. · No maternal, fetal, or neonatal adverse effects reported.. · Case examples illustrate safety and diagnostic value.. Citation Format:· Begaj K, Sperr AG, Clevert DA. Contrast-Enhanced Ultrasound (CEUS) in Pregnancy: A Comprehensive Review of Clinical Applications. Rofo 2026; DOI 10.1055/a-2784-9759.

Multiparametric ultrasound (MPUS) integrates B-mode, Doppler techniques and microvascular imaging, contrast-enhanced ultrasound (CEUS) and elastography, enhancing diagnostic precision across a wide spectrum of scrotal diseases. Developed under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), these guidelines provide evidence-based recommendations for the clinical use of MPUS in scrotal imaging. Based on the Oxford Centre for Evidence-Based Medicine framework, this document outlines the diagnostic value of MPUS in acute scrotal pain, trauma, infertility, focal and extratesticular lesions, cryptorchidism, and testicular incidentalomas. The recommendations highlight CEUS as the reference method for vascular assessment and elastography as a complementary tool for tissue characterization. These guidelines aim to standardize MPUS practice and promote its integration into routine scrotal imaging.

Abstract Purpose Structured reporting (SR) offers standardized radiological documentation, enhancing clarity and reproducibility. However, its role in contrast-enhanced ultrasound (CEUS) for testicular tumors remains underexplored. This study evaluates urologist-perceived clarity, completeness, and clinical usefulness of SR compared to free-text reporting (FTR). Methods and materials In this retrospective, single-center study, 65 male patients with suspected testicular tumors underwent CEUS at LMU University Hospital. Reports were initially documented as FTRs by an experienced radiologist and later converted into SRs using Smart Reporting software. Four board-certified urologists independently assessed both formats using a structured questionnaire. Completeness, readability, trust, and impact on clinical decision-making were evaluated. Statistical analysis included McNemar’s test and the Wilcoxon signed-rank test, with α = 0.05. Results SRs significantly improved readability (97.3% vs. 10.0%, p < 0.001) and information extraction (98.8% vs. 91.9%, p < 0.001). However, completeness (56.9% vs. 60.8%, p = 0.427) and clinical decision support (85.7% vs. 84.9%, p = 0.152) were comparable. Trust in SRs was lower than in FTRs (4.92 vs. 5.22, p < 0.001), likely due to missing diagnostic parameters and retrospective SR generation. Conclusions SR was associated with improved reporting clarity and consistency but did not outperform FTR in completeness or clinical decision-making. Interdisciplinary collaboration in template development and the integration of classification systems could improve SR’s diagnostic value. Future prospective, multicenter studies should assess real-time SR implementation and its potential impact on reporting quality, communication, and outcome-based endpoints in prospective settings. Clinical relevance/application Structured reporting in multiparametric testicular ultrasound including CEUS improved perceived readability and facilitated information access for referring clinicians. However, SR showed no clear advantage over free-text reporting regarding completeness or clinical decision-making. The lower clinician trust in SR highlights the need for clinically tailored templates developed in interdisciplinary collaboration. The broader clinical value of SR in testicular imaging should be confirmed in prospective real-time studies incorporating outcome-based and workflow-related endpoints.

Hepatocellular carcinoma (HCC) requires nuanced treatment response assessment to balance oncologic control with preservation of liver function. CT and MRI, cornerstones of response evaluation, are often limited by contraindications to their use or indeterminate findings. The recently introduced ACR LI-RADS Contrast-Enhanced Ultrasound (CEUS) Non-Radiation Treatment Response Assessment (TRA) algorithm offers a real-time, radiation-free alternative for evaluating treated HCC after ablation, transarterial therapies, or surgical resection. This review summarizes the CEUS TRA lexicon, criteria, and application across common clinical scenarios, emphasizing its value as a troubleshooting tool when conventional imaging is non-evaluable due to artifacts, contrast limitations, or heterogeneous post-treatment changes. We highlight pitfalls unique to CEUS interpretation, including poor lesion visibility, resection cavity complexity, and the inability to assess extrahepatic disease. Emerging areas include CEUS assessment after radiation-based therapies and the potential for integration of Kupffer-cell–specific contrast agents. Together, these developments position CEUS as an increasingly important modality for precise, timely, and individualized management of HCC following non-radiation locoregional therapy.

Rapid-deployment and transcatheter aortic valve replacement (RDAVR and TAVR) are standard treatment options for aortic valve disease. The lack of uniformity in size labelling and potentially adverse hemodynamic effects emphasize the need for an in-depth comparison of available prostheses. State-of-the-art valves (INTUITY Elite, Perceval, SAPIEN 3 Ultra and Evolut PRO+) were implanted into a patient-specific 3D printed aortic phantom with an annulus size recommended for the evaluated valves. The model was incorporated into a flow loop setup. Analysis of hemodynamic parameters was performed using advanced cardiovascular imaging (4D flow MRI and vector (V) flow ultrasound (US)). US revealed systematic differences in flow rates between RDAVR and TAVR prostheses. 4D flow analysis revealed localized regions of elevated WSS heterogeneously distributed without relevant differences between the prostheses. RDAVR prostheses showed higher kinetic energy loss (EL) along the thoracic aorta in small- compared to large-diameter models. EOA estimations ranged from 2.02 to 2.69 cm2 for RDAVR to 1.71 cm2 for 23 mm TAVR. Pressure gradients varied strongly between prosthesis types. Blood flow characteristics presented notable differences between the considered prostheses. This interdisciplinary approach provides a foundation for interpreting clinical outcomes after TAVR or RDAVR and potentially reduce the risk of prosthesis-patient mismatch.

BackgroundImmune checkpoint inhibitors (ICIs) have emerged as a highly effective treatment option for patients with metastatic melanoma. As not all patients respond to ICI immunotherapy, imaging biomarkers are required to accurately monitor early response to therapy. Therefore, the aim of this study was to evaluate contrast-enhanced ultrasound (CEUS) with VEGFR2-targeted microbubbles for monitoring the effects of combined anti-PD-L1/anti-CTLA-4 immunotherapy in a murine melanoma model.MethodsMurine melanoma allografts (B16-F10) were implanted subcutaneously in n = 10 therapy and n = 10 control female C57BL/6 mice. CEUS with VEGFR2-targeted microbubbles was performed on day 7 and 12. The therapy group received 3 intraperitoneal injections on days 7, 9, 11 of combined anti-PD-L1/anti-CTLA-4 immunotherapy, the control group received a placebo. CEUS assessed tumour perfusion during an early vascular phase (wash-in area under the curve = WiAUC) and VEGFR2-specific binding during a late molecular phase (signal intensity at 8 minutes (SI8min) and 10 minutes (SI10min)). For pathophysiological validation immunohistochemistry was performed.ResultsAt follow-up, the CEUS perfusion parameter WiAUC demonstrated a significantly higher decrease in the therapy than in the control group (p = 0.021). At follow-up, the signal enhancement in the late phase was significantly lower in the therapy than in the control group (SI8min p = 0.003; SI10min p = 0.002). Immunohistochemistry revealed significantly more apoptotic tumour cells (p = 0.001), more tumour infiltrating lymphocytes (p = 0.049), lower tumour cell proliferation (p = 0.001), lower microvascular density (p = 0.003) and lower VEGFR2 expression (p = 0.003) in the therapy than in the control group.ConclusionsCEUS with VEGFR2-targeted microbubbles allowed for monitoring early treatment effects of a combined anti-PD-L1/anti-CTLA-4 immunotherapy on melanoma allografts with significantly lower tumour perfusion and significantly lower binding of VEGFR2-targeted microbubbles in the therapy than in the control group.

PURPOSE:Shear wave elastography (SWE) has been investigated as a complement to B-mode ultrasound for breast cancer diagnosis. Although multicenter trials suggest benefits for patients with Breast Imaging Reporting and Data System (BI-RADS) 4(a) breast masses, widespread adoption remains limited because of the absence of validated velocity thresholds. This study aims to develop and validate a deep learning (DL) model using SWE images (artificial intelligence [AI]-SWE) for BI-RADS 3 and 4 breast masses and compare its performance with human experts using B-mode ultrasound. METHODS:We used data from an international, multicenter trial (ClinicalTrials.gov identifier: NCT02638935) evaluating SWE in women with BI-RADS 3 or 4 breast masses across 12 institutions in seven countries. Images from 11 sites were used to develop an EfficientNetB1-based DL model. An external validation was conducted using data from the 12th site. Another validation was performed using the latest SWE software from a separate institutional cohort. Performance metrics included sensitivity, specificity, false-positive reduction, and area under the receiver operator curve (AUROC). RESULTS:The development set included 924 patients (4,026 images); the external validation sets included 194 patients (562 images) and 176 patients (188 images, latest SWE software). AI-SWE achieved an AUROC of 0.94 (95% CI, 0.91 to 0.96) and 0.93 (95% CI, 0.88 to 0.98) in the two external validation sets. Compared with B-mode ultrasound, AI-SWE significantly reduced false-positive rates by 62.1% (20.4% [30/147] v 53.8% [431/801]; P < .001) and 38.1% (33.3% [14/42] v 53.8% [431/801]; P < .001), with comparable sensitivity (97.9% [46/47] and 97.8% [131/134] v 98.1% [311/317]; P = .912 and P = .810). CONCLUSION:AI-SWE demonstrated accuracy comparable with human experts in malignancy detection while significantly reducing false-positive imaging findings (ie, unnecessary biopsies). Future studies should explore its integration into multimodal breast cancer diagnostics.

Contrast enhanced ultrasound (CEUS) offers a safe, reliable imaging option to establish a clinical diagnosis across a variety of multidisciplinary settings. This Expert Consensus Statement serves to outline expert opinion on what constitutes appropriate supervision and the essential components of safe CEUS practice. The purpose of this document is to empower institutions to allow sonographers, along with other trained medical professionals, to administer UCAs at the point of care, consistent with the updated scope of practice documentation and within the broad parameters of an individual’s training and licensure, while subject to appropriate supervision and meeting or exceeding minimum safety standards. This guidance was developed by the International Contrast Ultrasound Society and endorsed by the following organizations that represent ultrasound professionals: the British Society of Echocardiography, the Canadian Society of Echocardiography, the Society of Diagnostic Medical Sonography, the Society for Pediatric Radiology, the World Federation of Ultrasound in Medicine and Biology, the Brazilian College of Radiology, the Joint Review Committee for Diagnostic Medical Sonography, the Chinese Ultrasound Doctors Association, and the American Society of Neuroimaging. Additionally, this guidance document was affirmed or supported by the American Society of Echocardiography, the Association for Medical Ultrasound, and the Society for Vascular Ultrasound.

The use of contrast-enhanced ultrasound (CEUS) in clinical practice is theoretically limited to the licensed indications: focal liver lesions, breast, peripheral arterial system, and the heart. In reality, there has been a continuous expansion of the deployment of CEUS examinations to many other organs and body parts over the last 20 years. Many of these applications are a natural extension of the diagnostic capabilities of the CEUS examination, used to achieve a better imaging outcome. These applications have been supported by guidelines issued by scientific societies, detailing the application, accuracy, and safety of the clinical performance. Nevertheless, there are some areas in which it remains more difficult to establish the use of CEUS in the diagnostic pathway. In the pregnant patient, CEUS is an ideal examination-a natural extension of B-mode ultrasound, avoiding ionising radiation and iodinated contrast. The contrast agents used in ultrasound do not cross the placental barrier. Ultrasound in the paediatric patient is used widely, and extending this to a CEUS examination improves diagnostic capabilities, avoiding less child-friendly imaging techniques. The parent can be in the room at the time of the ultrasound examination. Other aspects of CEUS usage are hampered by the lack of physician engagement despite the proven advantages of the technique, the reduction in the morbidity associated with CT and MR imaging, particularly the contrast agents used in these modalities. Complex renal cyst classification, follow-up of blunt abdominal trauma and the surveillance following placement of an aortic stent graft are all areas of potential benefit to the diagnosis. All these are better imaged on a CEUS examination. Furthermore, cost savings can be achieved using CEUS, mostly by alleviating downstream costs of CT and MR imaging. CRITICAL RELEVANCE STATEMENT: CEUS use outside licensed uses is becoming established, driven by the unique ability to achieve diagnostic standards safely and with patient acceptability, pushing the boundaries in areas of abdominal trauma, pregnancy, paediatrics, aortic implants, and complex renal cysts. KEY POINTS: CEUS has a narrow range of licensed applications in medical imaging, but is used widely. An exclusively intravascular agent allows assessment of vascular flow at the capillary level. CEUS is extremely safe and can be used in many areas that require repeated high-resolution imaging.

Purpose:Contrast-enhanced ultrasound (CEUS) is a reliable tool to diagnose focal liver lesions, which appear ambiguous in normal B-mode ultrasound. However, interpretation of the dynamic contrast sequences can be challenging, hindering the widespread application of CEUS. We investigate the use of a deep-learning-based image classifier for determining the diagnosis-relevant feature washout from CEUS acquisitions. Approach:We introduce a data representation, which is agnostic to data heterogeneity regarding lesion size, subtype, and length of the sequences. Then, an image-based classifier is exploited for washout classification. Strategies to cope with sparse annotations and motion are systematically evaluated, as well as the potential benefits of using a perfusion model to cover missing time points. Results:Results indicate decent performance comparable to studies found in the literature, with a maximum balanced accuracy of 84.0% on the validation and 82.0% on the test set. Correlation-based frame selection yielded improvements in classification performance, whereas further motion compensation did not show any benefit in the conducted experiments. Conclusions:It is shown that deep-learning-based washout classification is feasible in principle. It offers a simple form of interpretability compared with benign versus malignant classifications. The concept of classifying individual features instead of the diagnosis itself could be extended to other features such as the arterial inflow behavior. The main factors distinguishing it from existing approaches are the data representation and task formulation, as well as a large dataset size with 500 liver lesions from two centers for algorithmic development and testing.

Background and Objective: Adverse pathology to high-risk prostate cancer (PCa) after radical prostatectomy (upgrading) poses a threat to risk stratification and treatment planning. The impact on sexual function, urinary continence, and health-related quality of life (HRQOL) remains unclear. Methods: From 2004 to 2024, 4189 patients with preop low-/intermediate-risk PCa (Gleason score 6 or 7a, PSA ≤ 20 ng/mL) underwent radical prostatectomy at our department and were analyzed. Primary endpoint was HRQOL, erectile function, and urinary continence. Secondary endpoint was rate of salvage therapies and biochemical-free survival. Propensity score matching was performed using “operative time”, “robot-assisted surgery”, “blood loss”, “nerve-sparing surgery”, “age”, and “BMI” to represent comparable surgical approach. Median follow-up was 39 months (Interquartile-range (IQR) 15–60). Key Findings and Limitations: Patients who were upgraded to high-risk PCa showed a higher rate of postoperative radiotherapy and androgen-deprivation therapy compared to patients who were not upgraded (21% vs. 7%, p < 0.001; 9% vs. 3%, p = 0.002). Five-year biochemical recurrence-free survival was 68% in the upgrading group vs. 84% in the no-upgrading group (p < 0.001). We saw no difference in patient-reported HRQOL, urinary continence, or erectile function. Multivariable analysis showed that postoperative upgrading was a significant risk for not achieving good overall HRQOL (OR: 0.77, 95% CI: 0.61–0.97, p = 0.028) during the follow-up. Conclusions and Clinical Implications: Although postoperative upgrading to high-risk PCa leads to worse oncologic outcomes and higher salvage therapy rates, this study indicates that its impact on health-related quality of life is minimal and should not deter a cautious approach to radical prostatectomy.

Objective To assess the added value of concurrent systematic randomised ultrasonography‐guided biopsy (SBx) to multiparametric magnetic resonance imaging (mpMRI)‐targeted biopsy and the additional rate of overdiagnosis of clinically insignificant prostate cancer (ciPCa) by SBx in a large contemporary, real‐world cohort. Patients and Methods A total of 1552 patients with positive mpMRI and consecutive mpMRI‐targeted biopsy and SBx were enrolled. Added value and the rate of overdiagnosis by SBx was evaluated. Primary outcome: added value of SBx, defined as detection rate of clinically significant PCa (csPCa; International Society of Urological Pathology [ISUP] Grade ≥2) by SBx, while mpMRI‐targeted biopsy was negative or showed ciPCa (ISUP Grade 1). Secondary outcome: rate of overdiagnosis by SBx, defined as detection of ciPCa in patients with negative mpMRI‐targeted biopsy and PSA level of <10 ng/mL. Results Detection rate of csPCa by mpMRI‐targeted biopsy and/or SBx was 753/1552 (49%). Added value of SBx was 145/944 (15%). Rate of overdiagnosis by SBx was 146/656 (22%). Added value of SBx did not change when comparing patients with previous prostate biopsy and biopsy naïve patients. In multivariable analysis, a Prostate Imaging‐Reporting and Data System (PI‐RADS) 4 index lesion (odds ratio [OR] 3.19, 95% confidence interval [CI] 1.66–6.78; P = 0.001), a PI‐RADS 5 index lesion (OR 2.89, 95% CI 1.39–6.46; P = 0.006) and age (OR 1.05, 95% CI 1.03–1.08; P < 0.001) were independently associated with added value of SBx. Conclusions In our real‐world analysis, we saw a significant impact on added value and added rate of overdiagnosis by SBx. Subgroup analysis showed no significant decrease of added value in any evaluated risk group. Therefore, we do not endorse omitting concurrent SBx to mpMRI‐guided biopsy of the prostate.

Ultrasound is the most used interdisciplinary imaging technique in clinical routine for assessment of renal pathologies. This includes the monitoring of cystic renal lesions, which can be classified as non-complicated or complicated and by means of occurrence as solitary or multifocal lesions. The Bosniak-classification (I-IV) classifies renal cysts in 5 different categories and is used for decisions of further clinical treatment. This classification was developed for computed tomography and has been adopted for magnetic resonance imaging as well as contrast-enhanced ultrasound. In the following review article, cystic kidney lesions and their differentiation using contrast-enhanced ultrasound are presented and an overview of the therapy options is given. In interventional procedures, CEUS can make a valuable contribution in histological sampling, reduce radiation exposure and, under certain circumstances, the number of interventions for the patient.

The aim of this study is to describe the anatomical and functional changes observed in multiparametric magnetic resonance imaging (mpMRI) during follow-up after focal therapy (FT) for localized prostate cancer (PCa). In this prospective study, we analyzed pre- and postoperatively acquired mpMRI of 10 patients after FT (7 days; 3, 6, 9, 12 months). 7/10 (70