Chest Sonography. Bearbeitet von Gebhard Mathis

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1 Chest Sonogrphy Bereitet von Gehrd Mthis 1. Auflge Buch. VII, 249 S. Hrdcover ISBN Formt (B x L): 19,3 x 26 cm Gewicht: 749 g Weitere Fchgeiete > Medizin > Sonstige Medizinische Fchgeiete > Sonogrphie, Ultrschll Zu Inhltsverzeichnis schnell und portofrei erhältlich ei Die Online-Fchuchhndlung eck-shop.de ist spezilisiert uf Fchücher, insesondere Recht, Steuern und Wirtschft. Im Sortiment finden Sie lle Medien (Bücher, Zeitschriften, CDs, ebooks, etc.) ller Verlge. Ergänzt wird ds Progrmm durch Services wie Neuerscheinungsdienst oder Zusmmenstellungen von Büchern zu Sonderpreisen. Der Shop führt mehr ls 8 Millionen Produkte.

2 2 The Chest Wll Gehrd Mthis nd Wolfgng Blnk The chest wll with the exception of the prietl pleur ehind the ris is well ccessed y sonogrphy ecuse of its position immeditely next to the ultrsound trnsducer (Ski et l. 1990). Any suspicious findings on plption of the chest (whether inflmmtory or neoplstic) my e n indiction for chest sonogrphy. Quite often the susequent procedure consists of sonogrphic control investigtions nd sonogrphy-guided spirtion. Chest trum is n excellent indiction for sonogrphy of the chest wll. Frctures of the ri nd the sternum cn e dignosed with gret ccurcy. Concomitnt conditions such s locl hemtom, pleurl effusion or pneumothorx cn lso e identified y sonogrphy (Mthis 1997). Indictions for sonogrphy of the chest wll: Pin Amiguous findings on plption Amiguous X-ry findings Chest trum Tumor stging Intervention Follow-up G. Mthis (*) Internistische Prxis, Bhnhofstrsse 16/2, 6830 Rnkweil, Austri e-mil: gehrd.mthis@cle.vol.t W. Blnk Klinikum m Steinenerg, Medizinische Klinik Akdemisches Lehrkrnkenhus der Universität Tüingen, Steinenergstrße 31, Reutlingen, Germny e-mil: lnk_w@kreiskliniken-reutlingen.de Pthologicl sonogrphy findings in the chest wll: 1. Soft tissue () Accumultion of fluid Hemtom Serom Lymphtic cyst Ascess () Tumors Lipom Firom Srcom Metstses Invsion y crcinom (c) Lymph nodes Inflmmtory lymph nodes Mlignnt lymphom Lymph node metstses 2. Bone () Frctures Ris Sternum Clvicle Scpul () Osteolysis metstses Bronchil crcinom Brest crcinom Prostte crcinom Multiple myelom Others G. Mthis (ed.), Chest Sonogrphy, DOI / _2, Springer-Verlg Berlin Heidelerg

3 12 G. Mthis nd W. Blnk 2.1 Soft Tissue Accumultion of Fluid Hemtom Depending on the erythrocyte content nd the degree of orgniztion hence lso depending on the ge of the lesion hemtoms my e ccompnied y vrious echo ptterns. They re usully nechoic or hypoechoic (Fig. 2.1). Occsionlly one finds fine, hzy centrl echoes. In rre cses there my e intermedite forms or denser echoes in the centrl region. Orgnized hemtoms my hve very inhomogeneous echoes Serom, Lymphtic Cyst Postopertive seroms re lrgely nechoic, round or izrre in shpe nd hve no cpsule. Lymphtic cysts re similr in terms of structure, usully round or ovl. The occluded lymphtic vessel cn e visulized (Fig. 2.2) Ascess The cellulr nd protein content of the cvity of n scess my result in different centrl structures. The content of scesses my e similr to tht of hemtoms. Differentition my e difficult ecuse intermedite stges such s infected hemtoms my e present. Cpsulr formtions of different degrees re n importnt distinction criterion for scesses. Floting internl structures my e present (Fig. 2.3). Fig. 2.1 A sucutneous hemtom fter lunt trum (H). At this site the hemtom is lrgely nechoic. A lrge quntity of fluid in the pleurl cvity (E) turns out to e hemothorx on puncture Tumors Lipom, Firom The echogenicity of lipoms nd firoms depends on their cellulr ft content, their connective tissue content, nd impednce differences in interstitil tissue. The sonogrphic texture my vry from hypoechoic to reltively echodense forms nd the lesions my e poorly demrcted from the surrounding tissue. A cpsule my e present (Fig. 2.4) Srcoms, Soft-Tissue Metstses Invsive growth is one of the min criteri of mlignnt spce-occupying lesion. The texture is usully hypoechoic nd my e comined with inhomogeneous hyperechoic portions. Color-Doppler sonogr- Fig. 2.2 Pinful postopertive swelling in the lterl region of the neck on the left side. () Sonogrphy revels n echo-free, chmered spce-occupying lesion mesuring 10 cm 4 3 cm in size. () An occluded lymph trct (rrows) phy my e useful for the ssessment of hypoechoic structures suspected of mlignncy. The type of vsculriztion nd the course of the vessels my help to confirm suspected mlignnt lesion (Figs ). Knowledge of the vsculriztion pttern is lso very useful when performing sonogrphy-guided spirtion. At

4 2 The Chest Wll 13 Fig. 2.3 A pinful swelling in the region of the right xill is indictive of swet glnd scess. () Sonogrphy revels lrgely nechoic spce-occupying lesion mesuring 3 cm 1.5 cm in size. The modertely echogenic mrgin is indictive of strting cpsulr formtion. () Sonogrphy-guided spirtion yields pus. The residul fluid is sored Fig. 2.5 () Muscle lymphom. A 20-yer-old mn who experienced pin in the chest wll when exercising (odyuilding). Clinicl investigtion showed hrdening nd swelling in the pectorl muscles on the right side. On sonogrphy there ws hypoechoic trnsformtion in the lterl portions of the pectorlis mjor muscle, which ws interpreted s hemorrhge on B-mode sonogrphy. () Evidence of mrkedly vsculrized lesion on color-doppler sonogrphy; typicl vessels (corkscrew, fluctutions in dimeter, high-velocity signls). The surgicl iopsy reveled non-hodgkin s lymphom in the pectorl muscle Lymph Nodes Fig. 2.4 Modertely echogenic lipom in infrscpulr loction, with slightly lurred mrgins this fvorle loction close to the trnsducer, sonogrphyguided spirtion is most useful method to otin histologicl mteril nd finlly to confirm the dignosis. Sucutneous plple swellings re usully cused y lymph nodes. The sonomorphology of lymph nodes is indictive of their origin nd llows cutious ssessment of the enign or mlignnt nture of the lesion when viewed in conjunction with the clinicl condition. High-frequency proes yield differentited B-mode imge. The vsculriztion pttern on color-doppler sonogrphy imges provides further informtion out the type of lymph node (Bruneton et l. 1986; Hergn et l. 1994). The possiilities of ssessing the enign or

5 14 G. Mthis nd W. Blnk c d Fig. 2.6 () Hemngiom in the dorsl chest wll. Soft swelling on the left spect of the spine; the swelling hs een growing in the lst few yers. () Spce-occupying lesion t the level of the scpul with no invsion of the surrounding structures. (c, d) The spce-occupying lesion is of the vsculr type; it is supplied nd drined y prverterl vessels Fig. 2.7 Soft-tissue metstsis of srcom mlignnt nture of lesion hve een definitely improved y etter resolution of the B-mode imge s well s the use of vrious Doppler procedures to ssess the pttern of vsculriztion (Chng et l. 1994; Tschmmler et l. 1998; Tle 2.1). However, the enign or mlignnt nture of lesion should e estlished with cution on the sis of sonomorphologicl criteri lone; the finl ssessment cn only e mde y histologicl confirmtion of the dignosis fter spirtion or on the sis of disese progression. Chnges in size nd sonomorphology re of gret significnce in clinicl prctice. Thus, sonogrphy controls my e used to confirm the dignosis in

6 2 The Chest Wll 15 Fig. 2.8 () Solitry soft-tissue metstsis in prsternl loction 15 yers fter rest crcinom, confirmed y US-guided iopsy. () Resolution under rdiotherpy Tle 2.1 Sonomorphology of lymph nodes Morphology Mrgin Demrction Growth Moility Echogenicity Vsculriztion Inflmmtory Ovl, longitudinl Smooth Shrp Bed-like Good Hypoechoic mrgin signs of hilr ft Regulr, centrl cses of inflmmtory disese nd to document the success of therpy in cses of mlignnt lymph nodes Inflmmtory Lymph Nodes Inflmmtory lymph nodes seldom exceed 20 mm in size. Usully they hve smooth mrgins, re ovl, tringulr or longitudinl in shpe (Fig. 2.9). In cses of lymphdenitis, lymph nodes re typiclly rrnged in perl-like fshion long the lymph node sites. In keeping with the ntomy, one frequently finds more or less mrked echogenic centrl zone which is termed hilr ft sign, representing ft nd connective tissue in the center of the lymph node. This sign is seen prticulrly during the heling phse of inflmmtory processes (Fig. 2.10). The zone tht is shrply demrcted from the surrounding tissue is hypoechoic. In this region one frequently finds vessels running regulr course on Doppler ultrsound imges. The hilum of the lymph node with its rteries nd veins is lso visulized. Mlignnt lymphom Round, ovl Smooth Shrp Expnsive, displcing Good, moderte Hypoechoic, cystic Lymph node metstsis Round Irregulr Blurred Invsive Poor Inhomogeneous echoes Irregulr Corkscrew-like Mlignnt Lymphom A homogeneous, hypoechoic lesion with shrp mrgins is chrcteristic of mlignnt lymphom. Centrocytic nd Hodgkin s lymphoms re usully nerly nechoic in terms of structure nd look like cysts in such cses. Mlignnt lymphoms my e round, tightly ovl, or very rrely tringulr in shpe (Figs nd 2.12). The presence of vessels on oth sides (sndwich) is lso indictive of mlignnt lymphom. Mlignnt lymphoms my e strongly vsculrized, ut the vsculriztion my e irregulr in the mrgins.! Acutely inflmmtory lymph nodes look very similr to mlignnt lymphom

7 16 G. Mthis nd W. Blnk Fig. 2.9 Rective inflmmtory lymph node in the presence of listeriosis. () Hypoechoic mrgin, () regulr perfusion Fig Heling lymph node in the presence of tuerculosis. A nrrow hypoechoic mrgin nd lrge echogenic center Lymph Node Metstses Lymph node metstses pper inhomogeneous on the ultrsound imge. Modertely hyperechoic portions re often predominnt. The demrction to the surrounding tissue is usully lurred. Aggressive growth my e mnifested s invsion of muscles nd vessels (Gritzmnn et l. 1990; Fig. 2.13). The size of lymph nodes is n unrelile criterion. However, metstses re more often lrger thn the mximum size of 20 mm chieved y inflmmtory lymph nodes. Morphology is n importnt criterion. Metsttic lymph nodes tend to e round. One occsionlly finds rective lymph nodes in the vicinity of metsttic ones. The vsculriztion pttern of lymph node metstses is typicl: Vessels re frequently locted t the mrgin, irregulrly orgnized, run chotic course, flow in vrious directions, nd tend to chnge their color (Tschmmler et l. 2002). Nonplple lymph nodes cn lso e visulized; therefore, sonogrphy of the xill is recommended for preopertive stging nd monitoring the progress of rest crcinom (Bruneton et l. 1984; Hergn et l. 1996; Fig. 2.14). Since recently the sentinel lymph node is lso identified y sonogrphy. Currently, sonogrphy is routinely demnded for stging ronchil crcinom ecuse it is mrkedly superior to computed tomogrphy in showing lymph node metstses in the suprclviculr groove (N3) nd invsion of the chest wll (Suzuki et l. 1993). Nonplple lymph nodes re frequently discovered y this procedure (Fultz et l. 2002; vn Overhgen et l. 2004, Prosch et l. 2007). Sonogrphy discloses 17 36% more lymph nodes in this setting; in 3% the stging is upgrded. Further unnecessry investigtions re voided in out 10%. The cervicl lymph nodes must e serched for ecuse their presence indictes stge M1 disese.

8 2 The Chest Wll 17 Fig Hodgkin s lymphom. () At the time of dignosis. () After three chemotherpy cycles. Reduced in size y more thn 50%, then complete remission Fig B-cell chronic lymphocytic leukemi: hypoechoic lymph node with miniml hilr signs; strong nd somewht irregulr vsculriztion

9 18 Fig Lymph node metstsis of n epidermoid lung crcinom. Invsive growth into the vicinity. On plption the moility of the lesion ws mrkedly reduced. The ffected lymph node itself is chrcterized y inhomogeneous echoes, is onionshped in terms of structure, nd invdes its surroundings G. Mthis nd W. Blnk Fig 2.14 Nonplple xillry lymph node metstsis mesuring 7 mm in size, in the presence of rest crcinom Ultrsound is lso the most sensitive imging procedure when the investigtor is confronted with the question s to whether tumor is invding the chest wll. For one thing, the resolution in the re of the soft tissues using correspondingly high frequencies is unexcelled to dte. Furthermore, the dynmic investigtion is le to show whether the tumor is reth dependent in terms of motion. Therefore, the current S-3 guidelines demnd sonogrphy for stging in lung cncer (Goeckenjn et l. 2011). Lymph node metstses re good prmeters to monitor therpy. If the ptient responds to chemother- Fig () Cervicl lymph node metstsis of lrge-cell crcinom of the lung. () After two cycles of chemotherpy this lymph node metstsis hd resolved nd now looks like rective lymph node py or rdiotherpy, rective lymph nodes my persist (Fig. 2.15). 2.2 The Bony Chest Frctures of the Ris nd the Sternum Rdiologicl dignosis of the chest my prove difficult; nondislocted frctures re frequently not

10 2 The Chest Wll 19 Tle 2.2 Sonogrphy criteri for frctures of the ris nd the sternum Direct signs At the site of pin Corticl gp Step in corticl one Disloction Concomitnt indirect signs Hemtom Reverertion echoes/ chimney phenomenon Pleurl effusion Pneumothorx Lung contusion lesions seen. Lesions in the ris nd the sternum cn e visulized well y sonogrphy (Fenkl et l. 1992; DusKunz 1992; Dus-Kunz 1996; Bitschnu et l. 1997; Tle 2.2). The frcture gp, disloction nd one frgments re directly visulized. Soft-tissue hemtom, fluid in the pleur nd lung contusions re lso seen (Wüstner et l. 2005). The following procedure proved its worth in clinicl prctice: The ptient points to the site of mximum pin. This re is investigted. Quite often frcture cn e dignosed immeditely t this site. If the frcture gp is lrger thn the lterl resolution cpcity of the ultrsound device, the gp is directly ccessile to ultrsound dignosis which is usully the cse. A nondislocted frcture cn lso e identified indirectly y reverertion echoes the soclled chimney phenomenon. These reverertion rtifcts occur t the mrgins of the frcture frgments nd extend verticlly in depth. In the sence of disloction, the chimney phenomenon cn e triggered y gentle pressure on the site of pin. Frctures in the ri nd the sternum re chrcterized y the sme sonomorphology. The criteri re direct evidence of corticl gp or corticl step (Fig. 2.16), nd re indirect evidence of locl hemtom, chimney phenomenon or n ccompnying pleurl effusion (Fig. 2.17). Knowledge of the ntomy nd ntomicl vrints is the most importnt requirement for ssessment of the sternum. Thus, the usully discreet interruption of corticl one in the region of synchondrosis etween the corpus nd the mnurium of the sternum should not e mistken for frcture. Besides, vrious possiilities of incorrect fusion of ones, which my occur in rre cses, should e tken into ccount (Fig. 2.18). When monitoring the progression of disese one first finds locl hemtom s hypoechoic/nechoic mrgin in the region of the frcture gp. Susequent cllus formtion is mrked y initil orgniztion of Fig Ri frcture with step of 1.5 mm. This frcture could not e seen on X-rys. No ccompnying hemtom ove the frcture site Fig Ri frcture with reverertion echoes, the chimney phenomenon. In the sence of disloction this phenomenon cn e provoked y gentle pressure on the site of pin Fig Right: Frcture of the sternum fter rer-end collision (+ +). Left: the uneven surfce t the synchondrosis of the mnurium

11 20 G. Mthis nd W. Blnk Fig Ten-week-old ri frcture. Reclcified uneven protrusion t the previous frcture site the structure nd thickening. The strting clcifiction cuses fine coustic shdows nd my extend to complete ossifiction. Once ossifiction hs occurred, one my find just protrusion of the continuous, mrked corticl reflex (Fig. 2.19). Heling disorders lso cn e esily identified y the sence of continuous ossifiction. Thickening strts from the third or fourth week fter trum. Complete restitution is usully chieved fter few months (Friedrich nd Volkenstein 1994; Rieel nd Nsir 1995). The use of chest sonogrphy is n incresing procedure in trumtology (Leitge et l. 1990; Mricher Gehler nd Michel 1994). As n djunct to conventionl X-rys, sonogrphy provides significnt dditionl informtion (Griffith et l. 1999). In nonselected ptient popultion with suspected ri frctures, sonogrphy demonstrted twice s mny frctures s did chest X-rys, including trgeted X-ry (Bitschnu et l. 1997). Sonogrphy ws prticulrly useful to ssess the ventrl region. In cses of ri frctures in conjunction with frcture of the clvicle, however, conventionl X-rys were superior. For the ptient it is very importnt to estlish whether he/she hs chest contusion or frcture ecuse the two conditions hve different consequences for his/her ility to work. In cses of severe chest trum, the extent of n ccompnying pleurl effusion or hemtom or lung contusion (Fig. 2.20) cn e rpidly nd ccurtely estimted y sonogrphy. Thus, the use of sonogrphy is very meningful in the emergency setting (Wlz nd Muhr 1990; Wischofer et l. 1995; Wüstner et l. 2005). However, skin emphysem is limittion for sonogrphy (Fig. 2.21).

12 2 The Chest Wll 21 Fig Lung contusion: plte formed supleurl lung con solidtion Fig Emphysem of the skin. Numerous sucutneous ir reflections gretly impir the imge in terms of depth. The chest wll is not seen Osteolysis Osteolyses re usully metstses nd re chrcterized y n interrupted nd destroyed corticl reflex with pthologicl echo trnsmission (Fig. 2.22). Osteolytic metstses re usully seen s well-demrcted round or ovl spce-occupying lesions with prtly hypoechoic nd prtly rough echo structure. Color-coded duplex sonogrphy revels corkscrewlike neoformtion of vessels (Fig. 2.23). Fig () Cross section of n osteolytic ri metstsis in the presence of pleuropulmonry denocrcinom. () Longitudinl section of the metstsis. The ri is rised, the corticl reflex lrgely destroyed, the echotexture of the metstsis is inhomogeneous. The pthologicl echo trnsmission lso llows the pleur to e visulized Sonogrphy-guided spirtion is the procedure to e used if the clinicin wishes to mke histologicl dignosis of the osteolysis ecuse osteolyses re

13 22 G. Mthis nd W. Blnk Fig A highly mlignnt non-hodgkin s lymphom invding the ris, with pthologicl neoformtion of vessels on colordoppler sonogrphy. The dignosis ws estlished y sonogrphy-guided spirtion locted close to the trnsducer hed in very fvorle loction for sonogrphic dignosis. During ongoing therpy, osteolyses my serve s monitoring prmeters for the ony chest in the presence of diseses such s multiple myelom (Fig. 2.24), smllcell ronchil crcinom, prostte crcinom or rest crcinom. Any increse or decrese in size nd ny chnge in the sonomorphologicl internl structure cn e compred nd documented. Reclcifiction under therpy is seen erlier thn it is on X-rys. A peripherl ronchil crcinom invding the chest wll (Pncost s tumor) is etter ssessed y sonogrphy thn y computed tomogrphy; the sme is true for invsion of the suclvin vessels (Suzuki et l. 1993; Bndi et l. 2008; Figs nd 2.26).

14 2 The Chest Wll 23 Fig Multiple myelom with typiclly strong vsculriztion. The dignosis ws estlished y sonogrphy-guided iopsy 2.3 Summry Fig Lung crcinom growing into the upper perture of the thorx. ACC. crotis communis Visuliztion of lymph nodes nd cutious ssessment of the mlignnt or enign nture of lesion is n importnt indiction for sonogrphy of the chest wll. All miguous lesions in the chest wll re well ccessile to sonogrphy-guided spirtion for histologicl confirmtion of the dignosis, if such confirmtion is required for therpy. The risk of spirtion is very low owing to the fvorle loction of the lesions. Once mlignncy hs een proven, the progression of chest wll lesions under therpy cn e monitored.

15 24 Fig () Epidermoid crcinom t the right pex of the lung, in dorsl loction, invding the chest wll. () Irregulr vsculriztion pttern vsculr inferno Frctures of the ris s well s the sternum cn e visulized well y sonogrphy. Frcture dignosis y sonogrphy is not only much more sensitive thn with conventionl X-rys ut lso llows ccompnying soft-tissue lesions, hemtoms nd pleurl effusions to e detected rpidly nd relily. G. Mthis nd W. Blnk References Bndi V, Lunn W, Ernst A, Eerhrdt R, Hoffmnn H, Herth F (2008) Ultrsound vs. computed tomogrphy in detecting chest wll invsion y tumor: prospective study. Chest 133: Bitschnu R, Gehmcher O, Kopf A, Scheier M, Mthis G (1997) Ultrschlldignostik von Rippen- und Sternum frkturen. Ultrschll Med 18: Bruneton JN, Crmell E, Aunel D, Hery M, Ettore F, Boulil JL, Picrd L (1984) Ultrsound versus clinicl exmintion for xillry lymph node involvement in rest cncer. Ultrsound 153:297 Bruneton JN, Crmell E, Hery M, Aunel D, Mnzino JJ, Picrd L (1986) Axillry lymph node metstses in rest cncer: preopertive detection with US. Rdiology 158: Chng DB, Yun A, Yu CJ, Luh KT, Kuo SH, Yng PC (1994) Differentition of enign nd mlinnt cervicl lymph nodes with color doppler sonogrphy. Am J Roentgenol 162: Dus-Kunz B (1992) Sonogrphische Dignostik von Rippenfrkturen. In: Anderegg A, Desplnd P, Henner H, Otto R (eds) Ultrschlldignostik 91. Springer, Berlin/ Heidelerg/New York/Tokyo, pp Dus-Kunz B (1996) Sonogrphy of the chest wll. Eur J Ultrsound 3: Fenkl R, Grrel Tv, Knppler H (1992) Dignostik der Sternumfrktur mit Ultrschll eine Vergleichsstudie zwischen Rdiologie und Ultrschll. In: Anderegg A, Desplnd P, Henner H, Otto R (eds) Ultrschlldignostik 91. Springer, Berlin/Heidelerg/New York/Tokyo, pp Friedrich RE, Volkenstein RJ (1994) Dignose und Repositionskontrolle von Jochogenfrkturen. Ultrschll Med 15: Fultz PJ, Feins RH et l (2002) Detection nd dignosis of nonplple suprclviculr lymph nodes in lung cncer t CT nd US. Rdiology 222: Goeckenjn G, Sitter H, Thoms M et l (2011) Prevention, dignosis, therpy, nd follow-up of lung cncer: interdisciplinry guideline of the Germn Respirtory Society nd the Germn Cncer Society. Pneumologie 65:39 59 Griffith JF, Riner TH, Ching AS, Lw KL, Cocks RA, Metreweli C (1999) Sonogrphy compred with rdiogrphy in reveling cute ri frcture. AJR Am J Roentgenol 173: Gritzmnn N, Grsl MC, Helmer M, Steiner E (1990) Invsion of the crotid rtery nd jugulr vein y lymph node metstses: detection with sonogrphy. AJR Am J Roentgenol 154: Hergn K, Amnn T, Oser W (1994) Sonopthologie der Axill: Teil II. Ultrschll Med 15:11 19 Hergn K, Hid A, Zimmermnn G, Oser W (1996) Preopertive xillry sonogrphy in rest cncer: vlue of the method when done routinely. Ultrschll Med 17:14 17 Leitge N, Bodenteich A, Schweighofer F, Fellinger M (1990) Sonogrphische Frkturdignostik. Ultrschll Med 11:

16 2 The Chest Wll Mricher Gehler S, Michel BA (1994) Sonogrphy: simple wy to visulize ri frctures (letter). AJR Am J Roentgenol 163:1268 Mthis G (1997) Thorxsonogrphy Prt I: chest wll nd pleur. Ultrsound Med Biol 23: vn Overhgen H et l (2004) Metstses in suprclviculr lymph nodes in lung cncer: ssessment with plption. US CT Rdiol 232:75 80 Prosch H, Strsser G, Sonk C et l (2007) Cervicl ultrsound (US) nd US-guided lymph node iopsy s routine procedure for stging of lung cncer. Ultrschll Med 28: Rieel T, Nsir R (1995) Sonogrphie geurtstrumtischer Extremitätenläsionen. Ultrschll Med 16: Ski F, Sone S, Kiyono K et l (1990) High resolution ultrsound of the chest wll. Fortschr Röntgenstr 153: Suzuki N, Sitoh T, Kitmur S (1993) Tumor invsion of the chest wll in lung cncer: dignosis with US. Rdiology 187: Tschmmler A, Ott G, Schng T, Seelch-Goeel B, Schwger K, Hhn D (1998) Lymphdenopthy: differentition of enign from mlignnt disese color Doppler US ssessment of intrnodl ngiorchitecture. Rdiology 208: Tschmmler A, Beer M, Hhn D (2002) Differentil dingosis of lymphdenopthy: power Doppler vs color Doppler sonogrphy. Eur Rdiol 12: Wlz M, Muhr G (1990) Sonogrphische Dignostik eim stumpfen Thorxtrum. Unfllchirurg 93: Wischofer E, Fenkl R, Blum R (1995) Sonogrphischer Nchweis von Rippenfrkturen zur Sicherung der Frkturdignostik. Unfllchirurg 98: Wüstner A, Gehmcher O, Hämmerle S, Schenkench C, Häfele H, Mthis G (2005) Ultrschlldignostik eim stumpfen Thorxtrum. Ultrschll Med 26:

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