Carlos Nicolau

Evaluation of hepatocellular carcinoma using SonoVue, a second generation ultrasound contrast agent: correlation with cellular differentiation

The appearance of hepatocellular carcinoma (HCC) with contrast-enhanced ultrasound (CEUS) in the vascular phase is described and evaluated as to whether the enhancement pattern correlates with the degree of cellular differentiation. One hundred four HCCs were prospectively evaluated with CEUS using coherent-contrast imaging (CCI) and SonoVue with a low mechanical index (<0.2). The enhancement of HCCs in the vascular phase was analyzed according to the degree of pathological differentiation obtained by fine-needle biopsy. In the arterial phase, all HCCs except for four well differentiated ones (96.2%) showed enhancement (P<0.05). Histological differentiation of hypoechoic lesions in the early portal phase (7 HCCs; 16%) significantly differed from hyperechoic (1 HCC; 1%) or isoechoic lesions (87 HCCs; 83.6%) (P<0.05), with a significant probability of a worse differentiation in hypoechoic lesions. Histological differentiation of isoechoic lesions in the late phase (30 HCCs; 28.8%) significantly differed from hypoechoic lesions (74 HCCs; 71.2%) (P<0.05), with a significant probability of a better differentiation in isoechoic lesions. CEUS using CCI and SonoVue revealed enhancement in the arterial phase in >95% of HCCs, with a few well-differentiated cases not being diagnosed due to the absence of enhancement. Echogenicity in the portal and late phases correlated with cellular differentiation.

Importance of Evaluating All Vascular Phases on Contrast-Enhanced Sonography in the Differentiation of Benign from Malignant Focal Liver Lesions

OBJECTIVE Our objective was to evaluate the accuracy of a blood-pool sonographic contrast agent in the late phase compared with the three vascular phases for differentiation between benign and malignant focal liver lesions. SUBJECTS AND METHODS In 152 patients (105 with chronic liver disease), 152 solid focal liver lesions characterized either by fine-needle biopsy or by dynamic CT or MRI were studied. The final diagnoses were metastasis for 24, hepatocellular carcinoma for 75, focal nodular hyperplasia for 13, regenerating or dysplastic nodule for 14, hemangioma for 22, cholangiocarcinoma for two, and another focal liver lesion for two. Real-time sonography was performed after a bolus injection of 2.4 mL of SonoVue, using a low mechanical index (< 0.2). All lesions were evaluated in the arterial, portal, and late phases; classified as benign or malignant; and correlated with final diagnoses. RESULTS For discrimination between malignant and benign focal liver lesions, evaluation of all vascular phases improved the sensitivity from 78.4% to 98% and the accuracy from 80.9% to 92.7%, compared with evaluation of the late phase alone. The increase in accuracy was higher in patients with chronic liver disease (16.3%) than in those without (2.1%). CONCLUSION Evaluation of SonoVue enhancement in all three vascular phases is superior to evaluation of SonoVue enhancement in the late phase alone, especially in patients with chronic liver disease.

Development of aortic aneurysm/dilatation during the followup of patients with giant cell arteritis: A cross‐sectional screening of fifty‐four prospectively followed patients

OBJECTIVE Giant cell arteritis (GCA) may involve the aorta. Retrospective studies have demonstrated a higher prevalence of aortic aneurysm among patients with GCA compared with the general population. We investigated the prevalence of aortic aneurysm in a cohort of patients with biopsy-proven GCA using a defined protocol and assessed whether persisting low-grade disease activity is associated with higher risk of developing aortic aneurysm. METHODS Fifty-four patients with GCA (14 men and 40 women) were cross-sectionally evaluated after a median followup of 5.4 years (range 4.0-10.5 years). The screening protocol included a chest radiograph, abdominal ultrasonography scan, and computed tomography scan when aortic aneurysm was suspected or changes with respect to the baseline chest radiograph were observed. Clinical and laboratory data, corticosteroid requirements, and relapses were prospectively recorded. RESULTS Twelve patients (22.2%) had significant aortic structural damage (aneurysm/dilatation), 5 of them candidates for surgical repair. Aortic aneurysm/dilatation was more frequent among men (50%) than women (12.5%; relative risk 3.5, 95% confidence interval 1.53-8.01, P = 0.007). At the time of screening, patients with aneurysm/dilatation had lower serum acute-phase reactants, lower relapse rate, and needed shorter periods to withdraw prednisone than patients without aortic structural damage. CONCLUSION There is a substantial risk of developing aortic aneurysm/dilatation among patients with GCA. Our data do not support that aneurysm formation mainly results from persistent detectable disease activity. Additional factors including characteristics of the initial injury or the target tissue may also determine susceptibility to aortic aneurysm/dilatation.

Noninvasive Prediction of Clinically Significant Portal Hypertension and Esophageal Varices in Patients With Compensated Liver Cirrhosis

OBJECTIVES:We aimed to develop a model based on noninvasive variables for the prediction of clinically significant portal hypertension (CSPH) and of esophageal varices (EV) in patients with compensated liver disease.METHODS:Sixty patients with compensated liver cirrhosis diagnosed by histology were included in the training set. All patients had physical examination, laboratory tests, abdominal color-Doppler ultrasound, upper digestive tract endoscopy, and measurement of hepatic venous pressure gradient. Predictive models for the presence of CSPH and of EV were calculated. The models were validated in an independent series of 74 patients with compensated liver disease.RESULTS:Clinical and laboratory variables were selected in the final models, while ultrasonography did not add statistical power for the prediction of CSPH and EV. The model for prediction of CSPH included albumin, INR, and ALT. The best cutoff had 93% sensitivity and 61% specificity in the training set, and correctly classified 77% of patients in the validation set. Spider angiomas, ALT, and albumin predicted EV. The best cutoff of the model in the training set had a sensitivity of 93% and a specificity of 37% and correctly classified 72% of cases in the validation set.CONCLUSIONS:Noninvasive prediction of EV in well-compensated cirrhotic patients is not accurate. However, a model obtained by combining simple laboratory variables has a high sensitivity to predict CSPH in this population and may be useful to select the subset of patients requiring screening endoscopy. By this method, endoscopic screening could be obviated in about 40% of patients.

Characterization of focal liver lesions: comparative study of contrast-enhanced ultrasound versus spiral computed tomography

The purpose of this study was to compare the diagnostic accuracy of contrast-enhanced ultrasound (CEUS) with spiral computed tomography (SCT) for the characterization of focal liver lesions (FLL) and to determine the degree of correlation between the two techniques. Seventy-seven FLL (45 hepatocellular carcinomas; 12 metastases; ten hemangiomas; two regenerating/dysplastic nodules; eight focal nodular hyperplasias) detected with ultrasound (US) were prospectively evaluated by CEUS using a second-generation contrast agent and SCT (with an interval of no more than one month between the two techniques). Independent observers made the most probable diagnosis and the results were compared with the final diagnoses (histology n = 59; MRI n = 18). Statistical analysis was performed by the Chi-square and Kappa tests. CEUS provided a correct, specific diagnosis in 69/77 (90%) of the FLL, while SCT did so in 67/77 (87%). The sensitivity, specificity, and diagnostic accuracy for malignancy were 91%, 90%, and 91%, respectively, for CEUS and 88%, 89%, and 88%, respectively, for SCT. No statistically significant difference was found between CEUS and SCT in the characterization of FLL (p > 0.05). In addition, agreement between the two imaging techniques was good (k = 0.75). We conclude that CEUS and SCT provide a similar diagnostic accuracy in the characterization of FLL, with a good degree of correlation between the two techniques.

Sonography of Budd-Chiari Syndrome

OBJECTIVE The purpose of this pictorial essay is to review the color Doppler sonographic features of Budd-Chari syndrome. CONCLUSION Combining color and spectral data, sonography provides hemodynamic and anatomic information about vessel patency and collateral vessel formation. The diagnosis of Budd-Chari syndrome is based on the involvement of hepatic veins although intrahepatic collateral circulation and dilated caudate veins are also important and frequent signs. Half of the patients will develop regenerative nodules that can simulate hepatocellular carcinoma.

Early detection of hepatic artery thrombosis after liver transplantation by Doppler ultrasonography: prognostic implications.

We assessed the usefulness of routine Doppler ultrasonography for early detection of hepatic artery thrombosis after orthotopic liver transplantation and repercussions in patient prognosis. Seventeen confirmed cases of early hepatic artery thrombosis initially diagnosed by Doppler ultrasonography (10 of them before clinical indication) were reviewed. All patients underwent Doppler ultrasonographic studies in the first 3 days after orthotopic liver transplantation. Twelve cases of hepatic artery thrombosis (70.6%) were detected by this early Doppler ultrasonography. All 10 unsuspected cases of hepatic artery thrombosis and 5 of the 7 cases diagnosed after clinical indication were treated by revascularization. Grafts were salvaged in 80% of asymptomatic patients and in 42.8% of symptomatic patients. Furthermore, biliary complications were less serious in the first group. In conclusion, Doppler ultrasonography performed routinely in the first 3 days after orthotopic liver transplantation may permit early detection of hepatic artery thrombosis, even before clinical indications. This allows hepatic artery repermeabilization before liver function damage, improving graft rescue and patient prognosis.

Abdominal sonographic study of autosomal dominant polycystic kidney disease

The purpose of this study was to determine whether kidney size in patients who have autosomal dominant polycystic kidney disease (ADPKD) is related to renal function, hypertension, or extrarenal manifestations of the disease and to sonographically evaluate the abdominal manifestations of ADPKD.

Pathways of Lymphatic Spread in Male Urogenital Pelvic Malignancies

Regional lymph node involvement in urogenital malignancies (category N in the TNM classification system) is a significant radiologic finding, with important implications for treatment and prognosis. Male urogenital pelvic cancers commonly spread to iliopelvic or retroperitoneal lymph nodes by following pathways of normal lymphatic drainage from the pelvic organs. The most likely pathway of nodal spread (superficial inguinal, pelvic, or paraaortic) depends on the tumor location in the prostate, penis, testis, or bladder and whether surgery or other therapy has disrupted normal lymphatic drainage from the tumor site; knowledge of both factors is needed for accurate disease staging. At present, lymph node status is most often assessed with standard anatomic imaging techniques such as multidetector computed tomography or magnetic resonance (MR) imaging. However, the detection of nodal disease with these techniques is reliant on lymph node size and morphologic characteristics, criteria that provide limited diagnostic specificity. Functional imaging techniques, such as diffusion-weighted MR imaging performed with or without a lymphotropic contrast agent and positron emission tomography, may allow a more accurate nodal assessment based on molecular or physiologic activity.

Value of Doppler Sonography for Predicting Clinical Outcome After Renal Artery Revascularization in Atherosclerotic Renal Artery Stenosis

The purpose of this study was to prospectively evaluate the usefulness of Doppler sonography for predicting blood pressure and renal function improvement after percutaneous renal angioplasty in patients with unilateral atherosclerotic renal artery stenosis.