Alberto Tregnaghi

Differential Diagnosis of Benign and Malignant Thyroid Nodules at Elastosonography

PURPOSE Ultrasound of the neck detects a large number of non-palpable thyroid nodules in the population, but it offers poor diagnostic accuracy (the presence of microcalcifications is the only statistically significant criterion indicative of malignancy). The aim of this study is to evaluate elastography, a technique which allows differentiation between pathological and normal tissue by determining its hardness and which could also prove useful in the characterisation of thyroid nodules. MATERIALS AND METHODS In this prospective study, 51 thyroid nodules in 40 consecutive patients were examined (25 women, 15 men, mean age +/- SD, 54 +/- 13.4). Elastosonography was performed by real-time, free-hand technique, using Logos HiVision equipment with a 10 MHz transducer and lesions were classified and scored in 4 classes of hardness. All patients were also examined by grey scale high frequency ultrasound and colour Doppler. Final diagnoses were obtained from cytological and/or histological evaluation. RESULTS Final diagnoses revealed 11 malignant and 40 benign nodules. Only in two cases ultrasound demonstrated signs useful for a differential diagnosis (intrinsic microcalcifications). Correct differentiation of malignant from benign nodules was obtained by elastosonography in 43 / 51 cases with 5 false positives (FP) and 3 false negatives (FN). Specificity, sensitivity and accuracy were 87.5 %, 81.8 % and 86.2 %, respectively. Predictive negative value (PNV) and predictive positive value (PPV) were 94.5 % and 64 % area under the curve (AUC) 0.86. CONCLUSION Elastosonography provides an interesting contribution to the differentiation of malignant and benign thyroid nodules. Particularly worthy of mention is that an entirely elastic nodule pattern was observed only in relation to benign nodules, a result which would suggest that immediate recourse to FNAB might be avoided.

Bisphosphonate-associated jawbone osteonecrosis: a correlation between imaging techniques and histopathology

OBJECTIVES Recently, jawbone osteonecrosis has been reported as a potential adverse effect of bisphosphonates administration. This paper considers and highlights histopathologic and radiologic features of this condition. STUDY DESIGN Eleven patients, owing to unresponsiveness to conservative treatment and uncontrollable pain, underwent surgical resection of diseased jawbone after extensive hyperbaric oxygen therapy. A thorough clinical, laboratory, and imaging study was performed. Surgical specimens underwent histopathologic and immunohistochemical evaluation. RESULTS Computerized tomography (CT) scans showed increased bone density, periosteal reaction, and bone sequestration in advanced stages. With magnetic resonance imaging (MRI), exposed areas showed a low signal in T1- and T2-weighted and inversion recovery images, which suggests low water content and is histopathologically correlated with paucity in cells and vessels (osteonecrotic pattern). Unexposed diseased bone was characterized by T1 hypointensity and T2 and IR hyperintensity, which suggests high water content and inflammation, associated with hypercellularity, osteogenesis, and hypervascularity (osteomyelitic pattern). CONCLUSIONS Diseased bone extends beyond the limits of the bone exposed in the oral cavity. Histopathologic examination correlated well with CT and MRI, which are the choice for the evaluation of bisphosphonate-associated jawbone osteonecrosis.

Sensitivity and positive predictive value of CT, MRI and 123I-MIBG scintigraphy in localizing pheochromocytomas: a prospective study.

AimTo establish a standardized non-invasive imaging protocol for patients with pheochromocytoma undergoing surgery. MethodsA series of 32 consecutive patients (16 men, 16 women; median age 43 years, range 15–71 years) with biochemically confirmed pheochromocytoma underwent computed tomography (CT) scanning, magnetic resonance imaging (MRI) and meta-[123I]iodobenzylguanidine (MIBG) whole-body scintigraphy prior to adrenalectomy or excision of extra-adrenal tumour (paraganglioma). ResultsAt final pathology no malignant pheochromocytomas were found. The tumour was right-sided in 16 (50%) patients, left-sided in 13 (41%), extra-adrenal (sympathetic ganglia, upper abdomen) in two (6%) and bilateral in one (3%) patient. Overall, the median greatest diameter (size) of the tumour was 35 mm (range, 15–90 mm). The sensitivity of CT, MRI and MIBG scintigraphy was 90%, 93% and 91%, and the specificity was 93%, 93% and 100%, respectively. The three patients with false negative scintigraphy had an intra-adrenal tumour, ranging from 20 to 50 mm in size. The presence of necrosis within the mass might justify the lack of significant uptake of radiopharmaceutical in two patients, and the small size (15 mm) of the mass in the other. There were two false positive results with both CT and MRI, and no false positive MIBG scintigraphy, which had the highest (100%) positive predictive value. The combination of MRI+MIBG scintigraphy reached 100% sensitivity and positive predictive value. ConclusionOur data suggest that this imaging protocol should be used in all patients with biochemically confirmed pheochromocytoma.

Evaluation of Lymph Node Perfusion Using Continuous Mode Harmonic Ultrasonography With a Second-Generation Contrast Agent

Objective. To evaluate the contribution of continuous mode contrast‐enhanced harmonic ultrasonography (CE‐HUS) with a second‐generation contrast agent to the characterization of superficial lymphadenopathies with respect to conventional ultrasonographic techniques (B‐mode and power Doppler). Methods. Fifty‐six lymph nodes from 45 patients were studied both by conventional techniques and by CE‐HUS. The dimensions, intranodal architecture, margins, and location of vessels were evaluated. Subsequently, all the lymph nodes were examined by CE‐HUS, and enhancement of echogenicity was evaluated. The diagnoses obtained by means of fine‐needle aspiration cytologic examination, surgical biopsy, or both were compared with those obtained by ultrasonography. Results. Of the lymph nodes examined, 30 were benign and 26 were malignant (18 metastases and 8 non‐Hodgkin lymphomas). The study using CE‐HUS showed intense homogeneous enhancement in 28 of 30 reactive lymph nodes; perfusion defects in 17, of which 15 were neoplastic and 2 were inflammatory; intense but inhomogeneous speckled enhancement in the early arterial phase in 5 cases of lymphoma; and, last, scarce or absent intranodal enhancement in 4 metastases. The specificity, sensitivity, and accuracy of conventional techniques in differentiation between benign and malignant lymph nodes were 76%, 80%, and 78% versus 93%, 92%, and 92.8% for CE‐HUS. The increase in correct diagnoses was significant (P = .05) when conventional ultrasonography was tested against CE‐HUS. Conclusions. Superficial lymph nodes can be characterized as being neoplastic or benign with a high degree of diagnostic accuracy on the basis of the perfusion characteristics evaluated by CE‐HUS. This technique has been shown to afford a higher degree of accuracy than currently obtainable by any other ultrasonographic technique.

Comparison between transvaginal sonography, saline contrast sonovaginography and magnetic resonance imaging in the diagnosis of posterior deep infiltrating endometriosis

To compare clinical evaluation, transvaginal sonography (TVS), saline contrast sonovaginography (SCSV) and magnetic resonance imaging (MRI) in the diagnosis of posterior deep pelvic endometriosis (DPE).

The impact of ultrasound scanning in the staging and follow-up of patients with clinical stage I cutaneous melanoma.

In 85 patients with intermediate to high risk cutaneous melanoma, concomitant palpation and ultrasound scanning (US) of the axillary and inguinal sites were performed in order to detect any locoregional lymph node metastases at pre-operative staging and postoperative monitoring. At 12 months follow-up, US identified 12 out of 13 (92%) histologically proven metastases, while palpation indicated metastatic disease in only 3 (23%) patients. Metastases were intranodal in 6 out of 12 cases detected with US, and extranodal in all the 3 cases identified by palpation, thus confirming that US is more effective than palpation in the early detection of lymph node metastases from melanoma. US was also more effective in discriminating all non-neoplastic lymph nodes: its overall specificity was 100% versus 85% for palpation. Thus, when carried out by well-trained radiologists, US is a very useful diagnostic tool for the surgical oncologist dealing with melanoma patients.

Early (Sentinel Lymph Node Biopsy-Guided) Versus Delayed Lymphadenectomy in Melanoma Patients With Lymph Node Metastases: Personal Experience and Literature Meta-Analysis

It is debated whether patients with melanoma who undergo lymphadenectomy after a positive sentinel lymph node (SN) biopsy (SNB) have a better prognosis compared with patients who are treated for clinically evident disease.

CT-scan, MRI and image-guided FNA cytology of incidental adrenal masses.

AIM The aim of this study was to compare the usefulness of computed tomography (CT)-scan, magnetic resonance imaging (MRI), and fine-needle aspiration (FNA) cytology in patients with incidentally discovered adrenal masses. PATIENTS AND METHODS Thirty-four consecutive patients (six men and 28 women, median age of 47 years, range 26-80) with non-functioning adrenal masses of 2 cm or more (median 3.5 cm, range 2-9) were studied. All patients underwent CT-scan, MRI, and image-guided FNA cytology using spinal-type narrow-gauge needles prior to further procedures. Nineteen patients underwent adrenalectomy. RESULTS Final pathology showed 13 benign adrenal lesions, four adrenocortical carcinomas, and two unsuspected adrenal metastases. Fifteen patients who did not have surgery were considered definitively as having benign adrenal lesions since the mass was unchanged on CT-scans performed during follow-up. The sensitivity, specificity, and positive predictive value were 66.7, 85.7, and 50.0%, for CT-scan, 83.3, 92.9, and 71.4% for MRI, and 83.3, 100, and 100% (p<0.05) for FNA cytology, respectively. CONCLUSIONS Image-guided FNA cytology is a safe and sensitive procedure that may reveal unsuspected adrenal malignancies, and should be performed in all patients with incidentally discovered adrenal masses of more than 2 cm in size.

Primary inverted papilloma of the middle ear and mastoid.

Objective Inverted papilloma (Schneiderian-type papilloma), involving the middle ear and mastoid as a primary lesion or as an extension of a sinonasal papilloma, is an extremely rare occurrence. Study Design The study design was a case report format with a review of the literature. Epidemiologic, diagnostic, therapeutic and follow-up problems are discussed. Setting Academic, tertiary referral hospital. Patient and Methods The patient underwent Wullstein type I tympanoplasty and complete mastoidectomy, revealing obliteration of the pneumatic cells by polypoid tissue. The middle ear was completely filled by polypoid tissue. Histopathologic examination revealed an inverted papilloma of the middle ear and mastoid. Conclusion Literature reports indicate that inverted papillomas of the middle ear and mastoid differ pathogenically and epidemiologically from sinonasal inverted papillomas. Recurrence rates and association with squamous cell carcinoma are higher in Schneiderian-type papillomas of the middle ear than in inverted papillomas of the nose and paranasal sinuses. Long-term follow-up after removal of inverted papilloma of the middle ear and mastoid is mandatory. Magnetic resonance imaging is the first follow-up examination to perform.

Contrast-Enhanced Ultrasound for Characterizing Lymph Nodes With Focal Cortical Thickening in Patients With Cutaneous Melanoma

OBJECTIVE The aim of this study was to ascertain the utility of contrast-enhanced ultrasound in assessing the significance of focal cortical thickening in the lymph nodes of patients followed up after surgery for cutaneous melanoma. MATERIALS AND METHODS Ultrasound was used to examine 460 consecutive patients to identify nodes with focal hypoechoic cortical thickening. Patients whose nodes revealed these features underwent contrast-enhanced ultrasound and ultrasound-guided fine-needle aspiration cytology (FNAC) focusing on the area of cortical thickening. Enhancement in the arterial and parenchymal phases was evaluated: A generalized homogeneous or intense enhancement was considered benign and the presence of a perfusion defect was considered metastatic. RESULTS After exclusion of 24 patients with frank signs of malignancy at gray-scale ultrasound, the study included 436 patients. Focal hypoechoic cortical thickening was seen in 44 of 436 nodes in as many patients. In 29 nodes, the area of focal thickening showed contrast enhancement similar to that of the remaining cortex on contrast-enhanced ultrasound. In 15 nodes, the area of cortical thickening was less well vascularized than the adjacent parenchyma in the arterial phase and there were areas with perfusion defects that were more evident in the parenchymal phase. FNAC focusing on the areas of focal cortical thickening identified 13 metastatic nodes and 31 nodes with benign features. Contrast-enhanced ultrasound compared with FNAC correctly classified 42 of 44 nodes, showing a sensitivity of 100% and a specificity of 99.5%. CONCLUSION Although our findings need to be confirmed in larger series, they indicate that contrast-enhanced ultrasound can be useful in clinical practice for characterizing focal cortical thickening in lymph nodes. The exclusion or identification of regional lymph node metastases is of fundamental importance in oncologic staging because this issue directly influences both the prognosis and the choice of therapeutic strategy.