Adele Taibbi

FOCAL LIVER LESIONS: CONTRAST-ENHANCED ULTRASOUND

Contrast-enhanced ultrasound (CEUS) represents a significant breakthrough in sonography and it is being increasingly used for the evaluation of focal liver lesions (FLLs). The unique feature of CEUS of non-invasively assessing in real-time liver perfusion throughout the vascular phase has led to a dramatic improvement in diagnostic accuracy of US in either detection or characterization of FLLs, as well as in the guidance and evaluation of response of therapeutic procedures. Currently, CEUS is included as a part of the suggested diagnostic work-up of FLLs, resulting in a better patient management and cost-effective therapy delivering. After a brief description of the basis of different CEUS techniques, contrast-enhancement patterns of different types of benign and malignant FLLs, among hepatic pseudolesions, will be described and discussed on the basis of our experience and literature data. At the same time, the most recent concepts and the use of CEUS in different clinical settings will be presented.

Hepatocellular cancer response to radiofrequency tumor ablation: contrast-enhanced ultrasound

Radiofrequency ablation (RFA) is increasingly being used as percutaneous treatment of choice for patients with early stage hepatocellular carcinoma (HCC). An accurate assessment of the RFA therapeutic response is of crucial importance, considering that a complete tumor ablation significantly increases patient survival, whereas residual unablated tumor calls for additional treatment. Imaging modalities play a pivotal role in accomplishing this task, but ultrasound (US) is not considered a reliable modality for the evaluation of the real extent of necrosis, even when color/power Doppler techniques are used. Recently, newer microbubble-based US contrast agents used in combination with grey-scale US techniques, which are very sensitive to non-linear behavior of microbubbles, have been introduced. These features have opened new prospects in liver ultrasound and may have a great impact on daily practice, including cost-effective assessment of therapeutic response of percutaneous ablative therapies. Technical evolution of CEUS focusing on findings after RFA are illustrated. These latter are detailed, cross-referenced with the literature and discussed on the basis of our personal experience. Timing of CEUS posttreatment assessment among with advantages and limitations of CEUS are also described with a perspective on further technologic refinement.

Characterization of hypoechoic focal hepatic lesions in patients with fatty liver: diagnostic performance and confidence of contrast-enhanced ultrasound

The objective of this study was to assess the diagnostic performance of contrast-enhanced ultrasound (CEUS) to characterize hypoechoic focal hepatic lesions (HFHL) in fatty liver (FL). A study group of 105 patients with FL and 105 HFHLs (52 malignant and 53 benign) underwent CEUS after SonoVue administration. Two blinded readers independently reviewed baseline ultrasound (US) and CEUS scans and classified each lesion as malignant or benign on a five-point scale of confidence, and recorded whether further imaging work-up was needed. Sensitivity, specificity, areas under the receiver operating characteristic (ROC) curve (Az), and interobserver agreement were calculated. We observed that the diagnostic confidence improved after reviewing CEUS scans for both readers (Az=0.706 and 0.999 and Az=0.665 and 0.990 at baseline US and CEUS, respectively; p<0.0001). Inter-reader agreement increased (weighted k=0.748 at baseline US vs. 0.882 at CEUS). For both readers, after CEUS, the occurrence of correctly characterized lesions increased (from 27/105 [27.5%] to 94/105 [89.5%], and from 19/105 [18.1%] to 93/105 [88.6%], respectively; p<0.0001) and the need for further imaging decreased (from 93/105 [88.6%] to 26/105 [24.8%], and from 96/105 [91.4%] to 40/105 [38.1%], respectively; p<0.0001). We conclude that CEUS improves the diagnostic performance of radiologists in the characterization of HFHLs in FL and reduces the need for further imaging work-up.

Incidentally discovered thyroid nodules: incidence, and greyscale and colour Doppler pattern in an adult population screened by real-time compound spatial sonography

Purpose.Our aim was to assess the incidence and ultrasound features of thyroid nodules in an adult population screened by means of high-resolution ultrasonography (HRUS) and to evaluate the contribution of real-time spatial compound sonography (CS) in terms of image quality.Materials and methods.A total of 704 consecutive patients (400 women, 304 men) without thyroid disease underwent HRUS and CS examination of the thyroid gland. Number, size, location, echotexture and colour Doppler pattern of detected nodules were assessed. Two radiologists also assessed image quality of the two techniques.Results.Seven hundred and eleven thyroid nodules (size range 0.18–4.1 cm; mean: 1.1 cm) were detected in 233 subjects (33.1%). Of these, 416 (58.5%) were found in 143 women whereas 295 (41.5%) were detected in 90 men. In both genders, the number of detected nodules increased with age, with the highest prevalence in the seventh decade (p<0.001). There were 461/711 (64.9%) thyroid nodules that were hypoechoic, and 449/711 (63.1%) had peripheral vascularity only (p<0.001). Fineneedle aspiration (FNA) revealed no malignancies. CS was graded better than HRUS in 621/711 (87.3%) cases (p<0.001).Conclusions.The prevalence of benign, small, hypoechoic thyroid nodules with peripheral vascularity was high in our series, thus suggesting a conservative approach. CS provided better image quality compared with HRUS.

Hepatic focal nodular hyperplasia: contrast-enhanced ultrasound findings with emphasis on lesion size, depth and liver echogenicity

AbstractsObjectiveTo correlate contrast-enhanced ultrasound (CEUS) findings of hepatic focal nodular hyperplasia (FNH) with lesion size, depth and liver echogenicity and to compare CEUS with baseline US.MethodsTwo radiologists evaluated baseline US and CEUS examinations of 92 FNHs (mean size: 3.1u2009±u20091.7xa0cm) in 71 patients (59 women and 12 men) to detect the “spoke-wheel” sign, central scar and feeding vessel. The FNHs were grouped and analysed by dimension, depth and liver echogenicity.ResultsAt least one sign could be detected at CEUS in 27 out of 36 (75%) FNHs larger than 3xa0cm and in 17 out of 56 (30%) FNH measuring 3xa0cm or less (pu2009<u20090.0001). No statistically significant differences were noted between lesion depth or liver echogenicity and detection rate of these signs at CEUS (pu2009>u20090.05) as well as between CEUS or baseline US/CD with regard to lesion size, depth or liver echogenicity (pu2009>u20090.05).ConclusionThe detection rate of the central scar and spoke-wheel sign in FNH at CEUS is strongly dependent on lesion size and CEUS can confidently diagnose most FNHs larger than 3xa0cm.

Characterisation of focal liver lesions undetermined at grey-scale US: contrast-enhanced US versus 64-row MDCT and MRI with liver-specific contrast agent

PurposeThe aim of this study was to assess the role of contrast-enhanced ultrasonography (CEUS) in the characterisation of focal liver lesions in comparison with multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) with liver-specific contrast agent.Materials and methodsOne hundred and eighty-seven focal liver lesions, 91 malignant and 96 benign (mean size 3.2 cm) — proved by biopsy (n=12), histology (n=4), MDCT (n=108), MRI (n=44) MDCT/MRI (n=19) — in 159 patients were studied by CEUS. Two expert radiologists consensually evaluated the contrast-enhancement patterns at CEUS. For each lesion, they assessed: (a) nature (benign, malignant, not assessable), (b) specific diagnosis and (c) need for further radiological evaluation. Sensitivity, specificity, positive and negative predictive values and diagnostic accuracy of CEUS were calculated.ResultsA total of 167/187 (89.3%) lesions were correctly assessed as benign or malignant at CEUS, whereas 14/187 (7.5%) lesions remained undetermined and 6/187 (3.2%) were incorrectly assessed. Sensitivity, specificity, positive and negative predictive values and diagnostic accuracy of CEUS were, respectively, 89%, 89.6%, 89%, 89.6% and 89.3%. The need for further radiological evaluation decreased to 46/187 (24.6%) lesions after CEUS (p<0.001).ConclusionsIn selected cases, CEUS can be considered an effective alternative to MDCT and MRI and reduce the need for further radiological workup.RiassuntoObiettivoScopo del nostro studio è stato valutare il ruolo dell’ecocontrastografia nella caratterizzazione delle lesioni focali epatiche confrontandola con apparecchiature di tomografia computerizzata multidetettore (TCMD) e risonanza magnetica (RM) con mezzo di contrasto (MdC) epatospecifico.Materiali e metodiCentottantasette lesioni focali epatiche, 91 maligne e 96 benigne (diametro medio: 3,2 cm), in 159 pazienti, confermate mediante biopsia (n=12), istologia (n=4) TCMD, (n=108), RM (n=44) TCMD e RM (n=19), sono state studiate con ecocontrastografia, TCMD e/o RM. Due radiologi hanno valutato in consenso gli aspetti ecocontrastografici, indicando per ciascuna lesione: a) diagnosi di natura (benigna, indeterminata, maligna); b) diagnosi specifica; c) necessità di ulteriori indagini radiologiche. Sono stati calcolati sensibilità, specificità, valori predittivo positivo e negativo, nonché l’accuratezza diagnostica dell’ecocontrastografia.RisultatiL’ecocontrastografia ha consentito una corretta diagnosi (benigne vs maligne) in 167/187 (89,3%) casi. Quattordici/187 (7,5%) lesioni sono rimaste indeterminate e 6/187 (3,2%) non sono state correttamente caratterizzate dopo ecocontrastografia, con valori di sensibilità, specificità, valore predittivo positivo, negativo e accuratezza diagnostica pari, rispettivamente, all’89%, all’89,6%, all’89%, all’89,6% e all’89,3%. Dopo ecocontrastografia, la necessità di ricorrere a ulteriori indagini radiologiche si è ridotta a 46/187 casi (24,6%) (p<0,001).ConclusioniL’ecocontrastografia può essere considerata, in casi selezionati, una valida alternativa alla TCMD ed alla RM, riducendo il ricorso ad ulteriori indagini radiologiche.

Enhancement pattern of small hepatocellular carcinoma (HCC) at contrast-enhanced US (CEUS), MDCT, and MRI: Intermodality agreement and comparison of diagnostic sensitivity between 2005 and 2010 American Association for the Study of Liver Diseases (AASLD) guidelines

OBJECTIVEnTo evaluate agreement between contrast-enhanced ultrasound (CEUS), multi-detector row computed tomography (MDCT) and magnetic resonance imaging (MRI) for the assessment of typical and atypical enhancement patterns of small hepatocellular carcinoma (HCC); and to compare diagnostic sensitivity of 2005 and 2010 American Association for the Study of Liver Diseases (AASLD) guidelines.nnnMATERIALS AND METHODSnBetween January 2008 and December 2009, we included cirrhotic patients with newly diagnosed 10-20 mm HCC imaged at two contrast-enhanced imaging techniques among CEUS, MDCT, and MRI. Dynamic studies were reviewed by two radiologists to assess enhancement pattern. Percentage of cases with concordant findings and Cohen coefficient (k) were calculated. McNemars test was used to compare sensitivity between 2005 and 2010 AASLD guidelines.nnnRESULTSnThere were 91 patients (69 M; 22 F; mean age, 68 years) with 96 HCCs, studied with a combination of CEUS and MDCT (n=59), CEUS and MRI (n=26), or MDCT and MRI (n=11). Intermodality agreement for assessment of tumor enhancement pattern was 67% (k=0.294, P=0.001). Typical enhancement pattern was detected coincidentally at two imaging modalities in 50 (52%) HCCs. Sensitivity for the diagnosis of HCC increased significantly using the 2010 AASLD (81/96 (84%) vs. 50/96 (52%), P<0.001).nnnCONCLUSIONSnAgreement between two imaging modalities for the detection of typical tumor enhancement pattern was reached in 52% of cases. The 2010 AASLD guidelines significantly increased the sensitivity for the diagnosis of HCC.

Indeterminate focal liver lesions incidentally discovered at gray-scale US: role of contrast-enhanced sonography.

Objectives:To assess the role of contrast-enhanced ultrasound (CEUS) in the characterization of focal liver lesions (FLLs) incidentally discovered but indeterminate at gray-scale ultrasound (US). Materials and Methods:One hundred forty-two consecutive patients with 174 FLLs (169 benign and 5 malignant) incidentally discovered but indeterminate at gray-scale US, underwent CEUS after the administration of SonoVue. Two readers independently reviewed CEUS scans and: (1) classified each lesion as malignant or benign on a 5-point scale of confidence by means of definite diagnostic criteria; (2) provided if possible a specific diagnosis; (3) were requested if further imaging was needed for lesion characterization. Sensitivity, specificity, and areas under the receiver-operating characteristic curve (Az) as well as interobserver agreement were calculated. Results:At CEUS, both readers correctly differentiated benign from malignant lesions in 168 of 174 (96.5%) cases (P < 0.0001). A specific correct diagnosis was provided in 123 of 174 (70.7%) and 127 of 174 (72.9%) cases for reader 1 and 2, respectively (P < 0.0001). A further imaging study to characterize the lesion after CEUS was requested in 67 cases (38.5%) for reader 1 (P < 0.001) and 46 cases (26.4%) for reader 2 (P < 0.001). Receiver-operating characteristic analysis after CEUS revealed Az value of 1 for both readers and sensitivity and specificity values of 100% and 97.04% for reader 1 and 100% and 96.45 for reader 2 respectively (P < 0.0001). Inter-reader agreement at CEUS was good (weighted k = 0.779). Conclusion:CEUS improves the diagnostic performance of radiologists in the characterization of indeterminate FLLs incidentally discovered at US and reduces the need for further radiologic work-up.

Digital cineradiographic study of swallowing in patients with amyotrophic lateral sclerosis

PurposeThis study was performed to evaluate the usefulness of digital cineradiography in detecting swallowing disorders in dysphagic patients affected by amyotrophic lateral sclerosis (ALS) with a view to planning an adequate therapeutic approach.Material and methodsFrom January 2005 to September 2006, 23 patients (10 men and 13 women; mean age 41.3±8.6 years) affected by ALS were evaluated with digital cineradiography to assess the grade of dysphagia. All patients were classified using the Hillel ALS Severity Scale (ALSSS). All examinations were performed with radiocontrolled equipment provided with a digital C-arm.ResultsThe cineradiographic technique enabled us to differentiate patients with disorders of the oral (17/23) and/or pharyngeal (19/23) swallowing phase from those without swallowing dysfunction (4/23). In 14/23 patients, passage of contrast medium into the upper airways was observed during swallowing, whereas in 5/23 cases, aspiration of contrast medium into the lower airways was recorded.ConclusionsThe videofluoroscopic swallowing study has high diagnostic capabilities in the evaluation of swallowing disorders, as it is able to identify the degree and causes of impairment. In addition, the study proved useful for planning speech therapy and for follow-up in patients with ALS.RiassuntoObiettivoScopo del nostro lavoro è quello di valutare il ruolo della videofluorografia (VDFG) nell’identificazione delle alterazioni deglutitorie dei pazienti disfagici affetti da sclerosi laterale amiotrofica (SLA), anche al fine di programmare una adeguata pianificazione terapeutica.Materiali e metodiDal gennaio 2005 al settembre 2006, 23 pazienti (10 uomini e 13 donne; età media 41,3±8,6 anni) affetti da SLA e classificati secondo la classificazione ALS Severity Scale (ALSSS) di Hillel sono stati sottoposti a studio videofluorografico della deglutizione. Tutti gli esami sono stati eseguiti utilizzando un apparecchio telecomandato con arco a C digitale.RisultatiLa tecnica videofluorografica utilizzata ha permesso di differenziare i pazienti con alterazioni deglutitorie, 17/23 con alterazioni della fase orale e 19/23 con alterazioni della fase faringea (19/23 pazienti), da quelli che non presentavano alterazioni 4/23. In 14/23 pazienti sono stati evidenziati fenomeni di penetrazione del bolo in laringe, ed in 5/23 pazienti fenomeni di aspirazione del bolo al di sotto del piano glottico.ConclusioniLo studio videofluorografico della deglutizione è una tecnica dotata di elevata capacità diagnostica per la valutazione dei deficit deglutitori, essendo in grado di identificarne il grado di compromissione e le cause determinanti. Lo studio dinamico della deglutizione si è inoltre dimostrato utile nell’approccio alla terapia logopedica e nel follow-up dei pazienti affetti da SLA.

Focal lesions in cirrhotic liver: what else beyond hepatocellular carcinoma?

Detection and characterization of focal lesions in the cirrhotic liver may pose a diagnostic dilemma. Several benign and malignant lesions may be found in a cirrhotic liver along with hepatocellular carcinoma (HCC), and may exhibit typical or atypical imaging features. In this pictorial essay, we illustrate computed tomography and magnetic resonance imaging findings of lesions such as simple bile duct cysts, hemangioma, focal nodular hyperplasia-like nodules, peribiliary cysts, intrahepatic cholangiocarcinoma, lymphoma, and metastases, all of which occur in cirrhotic livers with varying prevalences. Pseudolesions, such as perfusion anomalies, focal confluent fibrosis, and segmental hyperplasia, will also be discussed. Imaging characterization of non-HCC lesions in cirrhosis is important in formulating an accurate diagnosis and triaging the patient towards the most appropriate management.