Emilio Quaia

Comparison of contrast-enhanced ultrasonography versus baseline ultrasound and contrast-enhanced computed tomography in metastatic disease of the liver: diagnostic performance and confidence

Aim: The aim of this study was to compare contrast-enhanced ultrasonography (CEUS) to baseline US and contrast-enhanced computed tomography (CT) in metastatic disease of the liver diagnosed or suspected by US during presurgical staging or postsurgical follow-up for primary malignancies. Materials and methods: Two hundred-fifty-three patients considered suitable for US due to the complete explorability of the liver and with one to five proven or suspected liver metastases at baseline US were included. All patients underwent US before and after microbubble injection, and multiphase contrast-enhanced CT. Independent panels of readers reviewed US and CT scans and recorded liver metastases according to a 5-grade scale of diagnostic confidence. Sensitivity, specificity (diagnostic performance) and area under the receiver operating characteristics (ROC) curve (diagnostic confidence) were calculated. Results: Reference standards revealed no metastases in 57/253, more than five in 59/253, and one to five in 137/253 patients. In patients with one to five metastases, CEUS versus baseline US revealed more metastases in 64/137 and the same number in 73/137 patients while CEUS versus CT revealed more metastases in 10/137, the same number in 99/137, and lower number in 28/137. Sensitivity, specificity, and area under ROC curve of CEUS (83%, 84%, 0.929, respectively) differed from baseline US (40%, 63%, 0.579, respectively; P<0.01) while did not differ from CT (89%, 89%, 0.945, respectively; P>0.05). Conclusion: CEUS improved liver metastases diagnosis in comparison with baseline US while it revealed similar diagnostic performance and confidence to contrast-enhanced CT in patients considered suitable for US and with proven or suspected liver metastases at baseline US.

Diagnostic value of hepatocellular nodule vascularity after microbubble injection for characterizing malignancy in patients with cirrhosis.

OBJECTIVEnThe purpose of this study was to assess the diagnostic value of hepatocellular nodule vascularity after microbubble injection for characterization of malignancy in patients with cirrhosis of the liver.nnnMATERIALS AND METHODSnAfter sulfur hexafluoride-filled microbubble injection, the vascularity of 236 hepatocellular nodules (1-5 cm in diameter) in 215 patients with cirrhosis (151 men, 64 women; mean age, 62 +/- 11 [SD] years) was evaluated by consensus of three reference radiologists. The relation between nodule vascularity in the arterial (10-40 seconds from injection) and portal venous (45 seconds to microbubble disappearance) phases and dimension of malignancy was evaluated by multivariate U statistical analysis. Two blinded independent reviewers using reference criteria classified nodules as benign or malignant after review of unenhanced and contrast-enhanced sonograms.nnnRESULTSnThe final diagnoses were 96 malignant (84 hepatocellular carcinoma, 12 tumors not hepatocellular carcinoma) and 140 benign nodules (57 regenerative and 13 dysplastic nodules, 70 other benign lesions). Nodule hypervascularity during the arterial phase and hypovascularity during the portal venous phase (odds ratio, 27.78) and nodule diameter greater than 2 cm combined with hypervascularity during the arterial phase and isovascularity or hypervascularity during the portal venous phase (odds ratio, 3.3) were related to the presence of malignancy. Contrast-enhanced sonography improved diagnostic accuracy (unenhanced sonography vs contrast-enhanced sonography, 32% vs 71% for reviewer 1 and 22% vs 66% for reviewer 2; p < 0.05, McNemar test) even though hypervascular nodules 2 cm or smaller (malignant, n = 2; benign, n = 40) that appeared isovascular or hypervascular during the portal venous phase were misclassified.nnnCONCLUSIONnAssessment of hepatocellular nodule vascularity after microbubble injection allowed characterization of malignancy, but characterization was limited for hypervascular nodules 2 cm or less in diameter.

Comparison of Visual and Quantitative Analysis for Characterization of Insonated Liver Tumors After Microbubble Contrast Injection

OBJECTIVEnThe objective of our study was to compare diagnostic performance of visual and quantitative analysis for the characterization of liver tumors insonated at low transmit power after microbubble contrast agent injection.nnnSUBJECTS AND METHODSnThis series comprised 166 liver tumors (1-5 cm in diameter) in 166 patients (99 men, 67 women; mean age +/- SD, 58 +/- 11 years) scanned at low transmit power (mechanical index: 0.1-0.14) after sulfur hexafluoride-filled microbubble injection. Digital cine clips recorded at the arterial phase (10-40 sec after contrast injection) and late phase (100-300 sec) were analyzed to characterize liver tumors as benign or malignant. Visual analysis was performed by three independent blinded reviewers who evaluated enhancement patterns at the arterial phase and subjective tumor conspicuity at the late phase. Quantitative analysis of videotape intensity (VI: gray-scale levels, 0-255) was performed to calculate objective tumor conspicuity at the late phase: (VI(tumor) - VI(liver)) / VI(liver).nnnRESULTSnCharacteristic enhancement patterns were observed in malignant tumors (peripheral rimlike) and benign tumors (peripheral nodular or central and spoke-wheel-shaped). Malignant (n = 95) versus benign (n = 71) tumors differed for subjective (median value: -1 vs 1, respectively) and objective conspicuity at the late phase (-0.6 vs 0.15, respectively; p = 0.001, Mann-Whitney U test) due to persistent microbubble uptake in benign tumors. Diagnostic performance of visual (odds ratio: reviewer 1 = 4.28, reviewer 2 = 10.18, reviewer 3 = 9.56) and quantitative (odds ratio: 89.33) analyses differed significantly in the characterization of liver tumors (p = 0.01, chi-square test).nnnCONCLUSIONnQuantitative analysis revealed higher diagnostic performance than visual analysis to characterize liver tumors insonated at low transmit power after microbubble contrast agent injection.

Painful Penile Induration: Imaging Findings and Management

A number of benign and malignant diseases with different causes, clinical features, management, and outcome can manifest as painful penile induration. The most common such conditions are active Peyronie disease, inflammation, trauma, venous or corporal thrombosis, acute ischemic disorders, and primary or secondary tumors. In patients with painful penile induration, a preliminary differential diagnosis is based on the patients history and results of laboratory studies, penile inspection, and palpation. Imaging is often required to confirm the clinical diagnosis, assess the extent of disease, and determine patient treatment. A basic clinical investigation comprising penile inspection and palpation should be performed by the radiologist before imaging; such an evaluation is a great help in selecting the best imaging modality and examination technique. Moreover, acquisition of preliminary clinical information eases interpretation of the imaging features and facilitates identification of clinically relevant information that may result in a change in patient treatment. In standard clinical practice, color Doppler ultrasonography is often the first imaging modality used to evaluate patients with painful penile induration. This technique clearly demonstrates normal penile anatomy and its corresponding changes in most of the clinically relevant situations. Magnetic resonance imaging is the optimal imaging modality for tumor staging. Other imaging modalities are required less frequently.

Diffusion-weighted magnetic resonance imaging in the prediction and assessment of chemotherapy outcome in liver metastases

PurposeThis study assessed the capability of magnetic resonance (MR) diffusion-weighted imaging (DwI) with measurement of apparent diffusion coefficient (ADC) in both predicting and evaluating the response to chemotherapy (CHT) of liver metastases by itself and along with preliminary dimensional assessment.Methods and materialsPatients affected by liver metastases from cancers of the digestive tract and breast were prospectively enrolled and underwent computed tomography and MR-DwI before CHT (time 0) and 20–25xa0days after the beginning of the second cycle (time 3). Moreover, MR-DwI was performed 10–15 (time 1) and 20–25xa0days (time 2) after the beginning of the first cycle. Maximum diameter and mean ADC value (×10−3xa0mm2/s) of metastases were evaluated. Lesions were classified as progressive disease (PD), stable disease (SD) or partial response (PR) according to dimensional changes between time 0 and time 3, following RECIST 1.1 indications. Clinically, PD lesions were defined as nonresponding (NR), and SD and PR lesions as responding (R). Analysis of variance and ROC analyses were performed (significance at pxa0<xa00.05).ResultsEighty-six metastases (33 patients) were classified as follows: 15 PD, 39 SD and 32 PR without significant differences in mean ADC values among the groups before CHT and at all corresponding times. The mean ADC values of SD and PR groups at times 1 (respectively 1.66xa0±xa00.36 and 1.59xa0±xa00.23), 2 (1.72xa0±xa00.42 and 1.68xa0±xa00.37) and 3 (1.86xa0±xa00.44 and 1.73xa0±xa00.39) were significantly higher than the corresponding values at time 0 (1.50xa0±xa00.30 and 1.39xa0±xa00.33). An accurate cutoff value of ADC increase or diameter decrease for the early identification of R or NR lesions was not found.ConclusionThe pretreatment ADC value of a liver metastasis does not seem useful in predicting the CHT outcome. A trend towards early ADC increase, alone or occurring with dimensional decrease, may be a good indicator of a responding lesion.

Differentiation of Inflammatory from Fibrotic Ileal Strictures among Patients with Crohn's Disease through Analysis of Time–Intensity Curves Obtained after Microbubble Contrast Agent Injection

The aim of the study described here was to assess whether the analysis of time-intensity curves obtained after microbubble contrast agent injection could differentiate inflammatory from fibrotic ileal strictures among patients with Crohns disease. Sixty-five consecutive patients (40 male and 25 female; mean agexa0±xa0SD, 42.2xa0±xa012.22xa0y) with stricture of the terminal ileal loop from Crohns disease were scanned after microbubble injection. Time-intensity curves were obtained from quantitative analysis, and peak enhancement, rise time, time to peak, area under the time-intensity curve (AUC), AUC during wash-in (AUCWI) and AUC during wash-out (AUCWO) were compared between patients with inflammatory strictures and patients with fibrotic strictures. Inflammatory (nxa0=xa040) and fibrotic (nxa0=xa025) strictures differed (pxa0<xa00.05) in peak enhancement, wash-in rate, wash-in perfusion index, AUC, AUCWI and AUCWO. The quantitative analysis of small bowel wall contrast enhancement after microbubble contrast agent injection may differentiate inflammatory from fibrotic ileal strictures in patients with Crohns disease.

Differentiation of Inflammatory From Fibrotic Ileal Strictures among Patients with Crohn's Disease Based on Visual Analysis: Feasibility Study Combining Conventional B-Mode Ultrasound, Contrast-Enhanced Ultrasound and Strain Elastography

The aim of this pilot study was to assess prospectively the feasibility of conventional B-mode ultrasound (US) and contrast-enhanced ultrasound (CEUS) combined with real-time strain elastography (SE) in the differentiation of inflammatory from fibrotic ileal strictures among patients with Crohns disease (CD) based on visual analysis. Twenty non-consecutive patients (15 male and 5 female; mean ageu2009±u2009standard deviation, 40.2u2009±u200910.22 y) with CD and stricture of the terminal ileal loop were scanned by conventional B-mode US and CEUS and, subsequently, by real-time SE. Two independent readers visually classified each bowel stricture as fibrotic or inflammatory based on conventional B-mode US, CEUS, SE, individually and then for all techniques combined. All techniques combined had a higher (pu2009<0.05) sensitivity (reader 1, 9/20 [45%]; reader 2, 7/20 [35%]), specificity (reader 1, 5/20 [25%]; reader 2, 8/20 [40%]) and diagnostic accuracy (reader 1, 14/20 [70%]; reader 2, 15/20 [75%]) and higher (pu2009<0.05) area under the receiver operating characteristic curve (reader 1, 0.953; reader 2, 0.921) than individual techniques. Inter-reader agreement was fair for conventional B-mode US (ku2009=u20090.46) and CEUS (ku2009=u20090.39), moderate for SE (ku2009=u20090.6) and fair for all techniques combined (ku2009=u20090.38). Conventional B-mode US and CEUS, in combination with SE, may improve differentiation of inflammatory from fibrotic ileal strictures among patients with CD based on visual analysis.

Pretherapeutic Diagnosis and Staging

The incidence of colorectal cancer has been rising dramatically following economic development. Currently, colorectal cancer is the third leading cause of cancer deaths in the United States and the second in Europe. Adenocarcinomas comprise the vast majority (98%) of colon and rectal cancers. Other rare rectal cancers include carcinoid (0.4%), lymphoma (1.3%), and sarcoma (0.3%). Squamous cell carcinomas may develop in the transition area from the rectum to the anal verge and are considered anal carcinoma.

Ultrasound of Upper Urinary Tract Infections

Urinary tract infection (UTI) is the most common bacterial infection. It accounts for 8.6 million visits in the ambulatory care setting in the United States. Women are at higher risk for UTI, with a self-reported annual incidence of 12%, and by the age of 32, half of them have suffered at least one UTI. Moreover UTI recurrence is high. Luckily acute pyelonephritis is much less common than cystitis, with a peak annual incidence of 25 cases per 10,000 women 15–34 years of age [1]. Infection is initiated when potential pathogens migrate from the bowel lumen to urethra and ascend to the kidneys. Accurate differentiation between uncomplicated UTI (episodes of acute cystitis and pyelonephritis in healthy premenopausal, non-pregnant woman, with no history suggesting abnormalities of urinary tract) and complicated UTI (all the other cases) is mandatory. Imaging helps in disease detection, definition its extent, reveal predisposing conditions and complications. Ultrasound is iexpensive, immediate, painless, widely available and radiation-free, so it should represents he first line imaging modality in the majority of patients. However uncomplicated UTI usually do not require imaging for diagnosis and treatment.

Ultrasound of Lower Urinary Tract Infections

Contrary to upper urinary tract infections (UTI), which affect almost exclusively the kidneys, lower UTI are a more complex entity, affecting several different portions of the genitourinary tract. They consist of a wide spectrum of manifestations, ranging from acute cystitis, which is the most common infection of all the urinary tract counting 0.70 episodes per person-year in young women and 0.07 episodes per person-year in postmenopausal women, to infrequent entities as schistosomiasis or life threatening disease such as Fournier’s gangrene. Enteric flora organisms like Escherichia Coli, Klebsiella Pneumoniae and Enterococcus species are the cause of disease in the vast majority of patients. The role of imaging techniques is strictly related to the severity of presentation varying between either end of possibilities: not required and mandatory. Ultrasound (US) is the technique of choice in most cases, however plain film and computer tomography (CT) may help the diagnostic workup in selected cases demonstrating peculiar findings.