Anders Elvin

Ultrasound and Power Doppler Evaluation of the Hand and Wrist in Patients with Psoriatic Arthritis

Purpose: To evaluate the ability of high‐resolution and power Doppler sonography in detecting joint and tendon abnormalities in patients with psoriatic arthritis (PsA) of the hands and wrists compared with clinical and radiological findings. Material and Methods: Thirty‐six patients with psoriatic arthritis of the hands and wrists and 10 healthy controls were examined with ultrasound (US). The degree of synovial proliferation, tenosynovitis, presence of joint effusion as well as the vascularity of synovial tissue was estimated. US findings were scored using a newly devised scoring system. Results: Thirty‐two patients had articular synovial proliferation and/or tenosynovitis/tendinitis or joint effusion in one or more joints according to US. Twenty‐two patients had tendon changes; only five had joint effusion. The synovial, Doppler, and total articular‐teno scores were all significantly correlated to the number of swollen joints. The scores, however, did not correlate to other clinical or laboratory measurements of disease activity. Conclusion: US proved effective in demonstrating PsA involvement of the hands and wrists and was more sensitive than clinical examination in detecting pathology. Long‐term follow‐up studies are needed to evaluate whether this can change the traditional approach for assessing involvement of joints and tendons in PsA.

Ultrasound guided tumour biopsy in the anterior mediastinum: An alternative to thoracotomy and mediastinoscopy

To evaluate percutaneous ultrasound (US) guided tumour biopsy of the anterior mediastinum all patients scheduled for open mediastinal biopsy were considered for percutaneous biopsy during a 2-year period. US guided biopsy was chosen when CT had shown the tumour to be in contact with the thoracic wall. US guided biopsy was performed in 23 patients on 28 occasions. The procedure was technically successful in all cases and no complications occurred. In 27 of 28 cases the biopsy diagnosis was identical to the final diagnosis. In one patient with a malignant lymphoma a false diagnosis of connective tissue remnant was reached. US guided tumour biopsy of the anterior mediastinum is a safe, cost-effective and reliable method and a good alternative to the traditional biopsy techniques via mediastinoscopy or thoracotomy.

Ultrasound-guided 1.2-mm cutting-needle biopsies of head and neck tumours

Purpose: to establish the role of ultrasound-guided cutting-needle biopsy in the diagnostic work-up of tumours in the head and neck region. Material and Methods: Seventy-two patients (74 biopsies) with tumours in the head and neck were biopsied by means of a biopsy gun fitted with a 1.2-mm biopty needle (midsized-needle biopsy, MNB). Twenty-four biopsies were taken from salivary glands, 29 from lymph nodes, and 21 from miscellaneous locations. Thirty-three of the patients were biopsied by MNB under ultrasound guidance after a blinded fine-needle aspiration biopsy (FNAB) was considered non-diagnostic or non-representative. Results: in 91% of the cases, the MNB diagnosis was identical to the final diagnosis (surgical or radiological/clinical follow-up: at least 6 months), 9% were false-negative/non-representative. in 17/33 patients MNB was considered to provide more diagnostic information than FNAB, the methods had equal accuracy in 12 patients, and in 4 patients the information already gained with FNAB was superior to that provided by MNB. the non-diagnostic sampling rate for FNAB was 25% versus 3% for MNB. in 26 patients with malignant lymphoma, MNB results were diagnostically correct in all but 2 cases. FNAB was correct in 2 of 9 cases. There were no biopsy-related complications. Conclusion: MNB was found to be safe and to possess a high degree of diagnostic accuracy, and could therefore, particularly in patients with lymphoma, be considered a diagnostic alternative to FNAB.

Significance of operator experience in diagnostic accuracy of biopsy gun biopsies

A total of 175 consecutive patients who had undergone a renal biopsy with a biopsy gun were evaluated retrospectively to assess the diagnostic accuracy rate of radiologists with varying experience in biopsy procedures. No statistically significant difference was found between the different operators. If provided with detailed instruction even operators with a limited amount of experience produced biopsy results equal to those of experienced operators. The automated sampling character of the biopsy gun, with a consistently high diagnostic sampling rate (96%), is believed to be responsible for these results. In a subgroup of 27 patients diagnostic accuracy was not found to be reduced in overweight patients.

Ultrasound guided tumour biopsy in the anterior mediastinum

To evaluate percutaneous ultrasound (US) guided tumour biopsy of the anterior mediastinum all patients scheduled for open mediastinal biopsy were considered for percutaneous biopsy during a 2-year period. US guided biopsy was chosen when CT had shown the tumour to be in contact with the thoracic wall. US guided biopsy was performed in 23 patients on 28 occasions. the procedure was technically successful in all cases and no complications occurred. in 27 of 28 cases the biopsy diagnosis was identical to the final diagnosis. in one patient with a malignant lymphoma a false diagnosis of connective tissue remnant was reached. US guided tumour biopsy of the anterior mediastinum is a safe, cost-effective and reliable method and a good alternative to the traditional biopsy techniques via mediastinoscopy or thoracotomy

Diagnostics of Malignant Lymphomas with Ultrasound Guided 1.2 MM Biopsy-Gun

In a retrospective analysis of 129 ultrasound-guided biopsy-gun biopsies (USGB) from patients with known or suspected malignant lymphoma, a histopathological diagnosis was obtained in 101 (78%) instances and no further procedures for histological verification were required. In the 28 cases with initially non-diagnostic results, 14 new USGBs were performed and a diagnosis was obtained in 11. Thus, a total success rate of 87% was achieved. The correct diagnosis was confirmed with either surgery, autopsy, or radiological or clinical follow-up (median 40 months). The diagnoses were categorised as Hodgkins disease and high-grade or low-grade non-Hodgkins lymphoma. Further subtyping of the lymphoma was possible in a few cases only. Immunohistochemistry was utilised only in a minor proportion of the cases (25/129), but refined the diagnosis in several instances. The biopsy-gun method was safe and minor adverse effects were seen in two patients only.

Ultrasound-guided biopsies of neuroendocrine metastases : comparison of 0.9 and 1.2 mm biopsy-gun needle biopsies

Twenty-five patients with known neuroendocrine tumour disease were biopsied with 1.2 mm and 0.9 mm biopsy-gun needles to evaluate the respective diagnostic accuracy of the 2 needle sizes. The influence of treatment-related fibrosis on the histopathological diagnosis was also evaluated. The overall diagnostic accuracy with the 0.9 mm needle was 69% as compared to 92% with the 1.2 mm needle. This difference, however, seems more related to needle guiding difficulties with the 0.9 mm needle than to insufficient tissue yield. When the tumour was hit with both the 0.9 and the 1.2 mm needle the tissue yield was inferior with the 0.9 mm needle in only one of 16 cases. The increased amount of fibrous tissue due to interferon treatment did not seem to negatively influence the diagnostic accuracy.

INTERFERON TREATMENT OF NEUROENDOCRINE TUMOUR XENOGRAFTS AS MONITORED BY MRI

The neuroendocrine-differentiated colonic carcinoma cell line (LCC-18) was transplanted to 29 nude mice (Balb/c). The purpose of the present study was to establish an animal model that would allow monitoring with magnetic resonance imaging (MRI) of changes induced by interferon (IFN) therapy and to evaluate whether the therapeutic response, as expressed by changes in MR signal characteristics and tumour proliferation activity, could be modulated by different IFN dosages. IFN did not seem to have any obvious antiproliferative effect on the LCC-18 tumour cell line transplanted to nude mice and no convincing treatment-related changes in rho values or T1 and T2 relaxation values were observed. The animal model was probably unsuitable for demonstration of IFN effects.

Therapy evaluation of neuroendocine liver metastases with contrast-enhanced MR imaging

Seventeen patients with neuroendocrine liver metastases, 14 of whom were treated with interferon, were examined with MRI before and after contrast administration to evaluate whether there were signal characteristics, differences in homogeneity and/or contrast enhancement patterns that indicated response to or failure of treatment. Of the treated patients 6 objectively responded to treatment (OR), 3 had progressive disease (PD) and 5 had stable disease (SD). A significant difference was found between the SD, untreated (UT) and OR groups of patients in terms of T1 (P = 0.01) and contrast enhancement (P = 0.02). The signal intensity ratio (SIR) in T2-weighted images between tumour and liver was significantly different (P = 0.05) between the OR and PD groups. This indicates that MRI may be used in therapy monitoring of patients with neuroendocrine metastases. Neuroendocrine metastases in the OR group had the same T1 and SIR values as those reported for haemangiomas, while patients in the PD, SD and UT groups had SIR values similar to those for colorectal metastases.

Editorial: Endosonography, the Last Frontier of Ultrasound?

The nicely illustrated review article, “Endosonography in Gastrointestinal Diseases” by ~DEGAARD et al. in this issue, summarises the current status of clinical usefulness of endosonography (EUS) in imaging pathological processes within and around the gastrointestinal (GI) tract. Intraluminal sonography has been a part of diagnostic ultrasound from the beginning. As early as 1955, WILD described the use of an echoendoscope for the location of rectal tumours. With the advent of laparoscopic and minimally invasive surgery, along with the rapid evolution of miniaturised probes, the interest for endoand intraluminal ultrasound has increased immensely. Transducers using frequencies in the range of 25-30 MHz can identify up to 11 layers of the GI tract wall. The theoretical use of endosonography for tumour staging is thus very good. However, there are three important issues that should be considered before a widespread use of the technique is recommended. Instrumentation: The mechanical 360” transducer is considered the baseline transducer which provides good anatomical orientation that facilitates identification and location of pathological structures in the GI wall and structures outside the GI tract. Traditionally, this transducer has been fitted at the end of a gastroscope. The cost for a state-of-the-art gastroscope is in the range of USD 150,000. With this kind of gastroscope there is no possibility for Doppler ultrasound or ultrasoundguided procedures, important features in the differential diagnosis of lymph nodes. The mechanical transducers represent an old technique without the inherent potentials of today’s digital equipment. The quality and resolution in the image, with tissue harmonics, multiple frequencies and power Doppler is much better. The cost for a machine with these features is also at least USD 150,000. Some investigators now perform the endosonography without the visual aid of the gastroscope. Already from the beginning, this may lead to a more widespread use of miniature probes which may reduce the initial cost of machine investment. Laparoscopic possibility is yet another feature that increases the cost for the machine investment. There are few, if any, manufacturers that provide all features mentioned, leading to heavy costs for the hospital interested in providing a full endosonographic service. Turfi Who should perform the endosonography? Today, the gastroscopies are, at least in Sweden, most commonly performed by the surgery or medicine departments. Endosonography therefore comes as an adjunct to existing endoscopic routines. The cross-sectional image expertise is naturally limited. In centres where the endosonography is performed by the radiologists, the gastroscopic techniques may initially be a limiting factor. The argument for keeping the endosonography at the radiological department could be that the hospital investments for equipment might be reduced. Instead of having machines at the urological, endorectal and endoscopic departments, a more effective use could be organised at one site. -Manufacturers could be encouraged and find it profitable to develop and provide these multiple uses on high-end machines. The strongest argument for keeping the endosonography within the realm of radiology is that this technique must be regarded as one of many to solve clinical problems. The limitations and merits of endosonography compared with MR imaging, CT and transabdominal US can best be assessed within radiology. This also assures that new innovations like Doppler, US contrast media and 3D US are rapidly implemented in the clinical practise. However, the argument for a combined clinical approach to solve these problems lies in the fact that we, as radiologists, cannot present our data