Boris Brkljačić

Staging of uterine cervical cancer with MRI: guidelines of the European Society of Urogenital Radiology

Objective: To design clear guidelines for the staging and follow-up of patients with uterine cervical cancer, and to provide the radiologist with a framework for use in multidisciplinary conferences. Methods: Guidelines for uterine cervical cancer staging and follow-up were defined by the female imaging subcommittee of the ESUR (European Society of Urogenital Radiology) based on the expert consensus of imaging protocols of 11 leading institutions and a critical review of the literature. Results: The results indicated that high field Magnetic Resonance Imaging (MRI) should include at least two T2-weighted sequences in sagittal, axial oblique or coronal oblique orientation (short and long axis of the uterine cervix) of the pelvic content. Axial T1-weighted sequence is useful to detect suspicious pelvic and abdominal lymph nodes, and images from symphysis to the left renal vein are required. The intravenous administration of Gadolinium-chelates is optional but is often required for small lesions (<2 cm) and for follow-up after treatment. Diffusion-weighted sequences are optional but are recommended to help evaluate lymph nodes and to detect a residual lesion after chemoradiotherapy. Conclusions: Expert consensus and literature review lead to an optimized MRI protocol to stage uterine cervical cancer. MRI is the imaging modality of choice for preoperative staging and follow-up in patients with uterine cervical cancer.

Fibrin Glue-Antibiotic Mixture in the Treatment of Anal Fistulae: Experience with 69 Cases

Background/Aims: To investigate the potential value of the use of the fibrin glue-antibiotic mixture in the treatment of anal fistulae. Materials and Methods: This study included 69 patients with idiopathic nonspecific anal fistulae. Patients with IBD (inflammatory bowel disease), TBC, actinomycosis, and cancer were excluded from the study. The microbiological analysis of the discharge of the fistula was done routinely. If there was any doubt about vertical classification of the fistulous tract MR of anal canal was necessary. As regards the vertical disposition, 39 fistulae were classified as intersphincteric and 30 as transsphincteric, and as to the length of the fistulous tract, 24 fistulas had tracts ≤3.5 cm long, and 45 fistulas had tracts >3.5 cm long. All fistulae were first treated with the lavage of the fistulous tract with antibiotic solution until a sterile microbiological finding was obtained. This was followed by electrocoagulation of the fistulous tract with a special probe for the eradication of granulomatous tissue. Finally the fibrin glue-antibiotic mixture (Tisseel, Immuno Ltd., Vienna, Austria) was applied. Results: After a follow-up of 18–36 months (median 28) 18 patients (26%) had a recurrence; among these, intersphincteric fistula recurred in 9 patients (23%) and transsphincteric also in 9 (30%). Regarding the length of the fistulous tract, a fistula with a ≤3.5 cm long tract recurred in 13 patients (54%) and a fistula with a >3.5 cm long tract in 5 (11%). Conclusion: The analysis showed that the success of the treatment of anal fistulae with fibrin glue-antibiotic mixture was independent of the vertical disposition of the fistula, and was dependent on the length of the fistulous tract. Surgical treatment remains a golden standard for simple fistulae with a tract ≤3.5 cm. Anal fistulae with a longer tract usually present a more complex problem and are often more difficult to treat surgically, the use of the fibrin glue-antibiotic complex proved to be a feasible method for those cases. It is a safe, cheap, reproducible, pain-free procedure, which eliminates the possibility of anal incontinence and can be performed under local anesthesia.

Smaller right hippocampus in war veterans with posttraumatic stress disorder

Chronic stress can putatively cause damage in the human hippocampus, but evidence of damage has not been consistently shown in studies on hippocampal morphology in posttraumatic stress disorder (PTSD). We compared hippocampal volumes in PTSD patients and normal subjects. Using a 3D T1-weighted GRE magnetic resonance imaging sequence, we measured hippocampal volumes in 15 war veterans with combat-related chronic PTSD and 15 case-matched normal controls. Although war veterans, our PTSD subjects were not professional soldiers and were mobilized shortly before they were exposed to a very specific combat-related trauma over a 3-day period. In our study, the period between traumatic exposure and imaging was considerably shorter, on average, 9 years, compared with at least two decades in previous studies on subjects with combat-related PTSD. Moreover, our subjects were free of any comorbidity, treatment or medication. The right hippocampus was significantly smaller in PTSD subjects than in healthy controls. The left hippocampus was also smaller in PTSD subjects than in controls, but the difference was not significant. In all PTSD subjects, the right hippocampus was smaller than the left (on average, 7.88%). Our results show smaller volume of the right hippocampus in PTSD patients than in normal subjects.

Ultrasound Assessment of Detrusor Muscle Thickness in Children with Non-Neuropathic Bladder/Sphincter Dysfunction

OBJECTIVE To measure detrusor muscle thickness in children with non-neuropathic bladder/sphincter dysfunction (NNBSD), and to evaluate the difference between children with various bladder dysfunctions and those with normal urodynamics. MATERIALS AND METHODS In 139 children the urodynamic study was performed, and the detrusor of the anterior bladder wall was measured using high-frequency ultrasonography (US). Children were categorized into five groups, according to urodynamic findings. Differences in detrusor thickness between groups were tested by one-way ANOVA with post hoc Scheffé test. RESULTS Forty-six children (33.1%) had normal urodynamics, and mean (+/-S.D.) detrusor thickness 1.3 +/- 0.5 mm (range 0.5-3.0). Fifty-two (37.4%) had urge syndrome, with detrusor thickness of 2 +/- 0.7 mm (1.0-3.6). Thirty-three (23.7%) had dysfunctional voiding, with detrusor thickness of 2.6 +/- 0.5 mm (1.5-3.6). Four (2.9%) had lazy bladder, with detrusor thickness of 0.9 +/- 0.1 mm (0.8-1.0), and four had anatomical infravesical obstruction, with detrusor thickness of 4.4 +/- 0.3 mm (4-4.6). The mean detrusor thickness in all children with NNBSD was 2.2 +/- 0.7 mm (range 0.8-3.6). Multiple comparisons showed significant difference between all groups, except between children with normal urodynamics and children with lazy bladder. CONCLUSION There is statistically significant difference in mean detrusor thickness between children with normal urodynamics and children with NNBSD. However, due to the overlap of measured values, it is not possible to determine the cut-off value that could be used to distinguish children with and without NNBSD.

Noninvasive Assessment of Liver Fibrosis with Acoustic Radiation Force Impulse Imaging: Increased Liver and Splenic Stiffness in Patients with Liver Fibrosis and Cirrhosis

PURPOSE To evaluate acoustic radiation force impulse imaging (ARFI) of the liver and spleen as a new method for the noninvasive assessment of liver fibrosis (LF). MATERIALS AND METHODS Three groups of 58 examinees were studied: (A) 20 healthy volunteers; (B) 18 patients with chronic viral hepatitis (CVH) B or C having liver fibrosis stages F 1 - 4 (assessed by liver biopsy; Ishak classification); and (C) 20 patients with liver cirrhosis (LC). All participants were examined using the Siemens ACUSON S 2000 Ultrasound Virtual Touch Tissue Quantification system. Ten measurements were performed on both liver lobes and three measurements on the spleen, and the obtained mean values (shear wave velocities [SWV] expressed in m/s) were compared between the groups. In 20 patients the splenic artery pulsatility index (SAPI) was also measured and correlated to the liver and splenic ARFI and histological stage of LF. RESULTS Hepatic ARFI measurements demonstrated a significant correlation to LB results (Spearmans ρ = 0.766; ρ < 0.001) and SWV cut-off values of 1.3 (AUC 0.96) and 1.86 (AUC 0.99) could reliably differentiate between healthy (A) and non-cirrhotic CVH (B), as well as between non-cirrhotic CVH (B) and LC (C). Splenic SWV cut-off value of 2.73 (AUC 0.82) could differentiate between the patients with LC and non-cirrhotic CVH. A significant correlation was also observed between the SAPI and liver ARFI results (ρ = 0.56; p = 0.013). CONCLUSION The hepatic and splenic SWV measured by ARFI increase with the LF stage, and the hepatic SWV correlate well with SAPI. This new technology enables simultaneous morphological, Doppler and elastometric examinations and might improve the accuracy of noninvasive liver fibrosis assessment.

Two Cases of Lethal Complications Following Ultrasound-Guided Percutaneous Fine-Needle Biopsy of the Liver

Two cases with lethal complications are reported among 1750 ultrasound (US)-guided percutaneous fine-needle liver biopsies performed in our department. The first patient had angiosarcoma of the liver which was not suspected after computed tomography (CT) and US studies had been performed. The other patient had hepatocellular carcinoma in advanced hepatic cirrhosis. Death was due to bleeding in both cases. Preprocedure laboratory tests did not reveal the existence of major bleeding disorders in either case. Normal liver tissue was interposed in the needle track between the liver capsule and the lesions which were targeted.

Intrarenal duplex Doppler sonographic evaluation of unilateral native kidney obstruction.

RIs were measured in intrarenal arteries in 66 kidneys of 33 examinees without renal impairment and in 42 kidneys of 21 patients with unilateral urinary obstruction. The mean RI in normal kidneys was 0.593 +/‐ 0.040. Patients with unilateral obstruction had a mean RI of 0.709 +/‐ 0.039 in obstructed kidneys and a mean RI of 0.591 +/‐ 0.033 in contralateral nonobstructed kidneys. Statistically significant differences have been noticed in the groups of normal versus obstructed kidneys (P < 0.001) and of obstructed versus contralateral nonobstructed kidneys (P < 0.001). The mean dRI was 0.118 +/‐ 0.034 in patients with unilateral obstruction, and it was 0.014 +/‐ 0.012 in examinees without renal impairment (P < 0.001). A comparison of RI values between the right and left kidneys in a patient with unilateral obstruction proved more useful than using a 0.7 RI cutoff value in a Doppler sonographic diagnosis of unilateral obstruction.

Diabetic nephropathy Comparison of conventional and duplex Doppler ultrasonographic findings

Background: the purposes of this study were: to compare conventional and duplex Doppler ultrasonography in the detection of renal changes in diabetes mellitus; to investigate whether a correlation was found with various clinical stages; and to assess whether increased renal vascular resistance in asymptomatic patients correlated with mild renal functional impairment. Material and Methods: in 190 diabetic patients and 85 controls, conventional ultrasonography was used to assess renal length, parenchymal thickness, and cortical echo-genicity. Renal vascular resistance was estimated by duplex Doppler measurements of intrarenal arterial resistive indices. According to clinical stage, the patients were classified into 3 groups. Resistive indices were compared between controls and patient groups and correlated with age and renal function. Results: in asymptomatic diabetic nephropathy, renal length and parenchymal thickness were significantly increased compared to that of controls, reflecting hyperfiltra-tion-induced nephromegaly. Differences between controls and patients with clinically manifest nephropathy were insignificant; only in advanced renal disease were both values significantly decreased. Cortical hyperechogenicity was noted only in very advanced disease. Resistive indices correlated well with renal function, and pathologic values (i. e. ≥ 0.70) were observed in 15% in the asymptomatic group and in 87% in the group with advanced nephropathy. Conclusion: Renal changes in diabetic patients are detectable by conventional ultrasound only in very advanced stages of the disease. Pathologic resistive indices, however, may be detected in the earlier stages. Resistive indices correlate with serum cre-atinine levels and creatinine clearance rates. However, it remains unclear as to whether a diagnostic or prognostic benefit can be expected as compared to standard laboratory examinations.

Doppler sonographic renal resistance index in healthy children.

Abstract. The objective of the study was to determine the values of Doppler resistance indices (RIs) in intrarenal arteries in healthy children. Color duplex Doppler sonography of intrarenal arteries was performed in 163 children and 58 adult patients, with the absence of clinical or laboratory pathologic changes of the urinary tract. All patients were classified following results of exploratory data analysis into three age groups: (a) 51 children between 2 and < 6 years of age; (b) 112 children 6–16 years of age; and (c) adults. The RIs were compared between different age groups. The mean RI ± 1 SD values in group 1 were 0.705 ± 0.018 (range 0.67–0.75), in group 2 0.605 ± 0.029 (range 0.55–0.65), and in the adult group 0.604 ± 0.035 (range 0.54–0.68). In the group of the youngest children (group 1), the RIs were significantly higher (p < 0.01) in comparison with the other group of children and the adult group. No statistically significant difference was observed between the group of children 6–16 years of age and the adult group. RI < 0.70 was noted in all children above 6 years of age; however, in younger children, RI ≥ 0.70 was observed in 72.5 % (37 of 51) of children. Resistance index in early childhood was considerably higher as compared with older children and the adult population: Apparently the RI value drops to adult level at approximately 6 years of age. The utilization of a threshold RI value of 0.70 for the increased renal vascular resistance in adults can also be applied to children over 6 years of age.

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part I. General Aspects (Short Version).

This is the first part of the Guidelines on Interventional Ultrasound of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) and covers all general aspects of ultrasound-guided procedures (short version; the long version is published online).