F. Vecchiato

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

OBJECTIVE The 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. MATERIALS AND METHODS After 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. RESULTS The 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. CONCLUSION Assessment of hepatocellular nodule vascularity after microbubble injection allowed characterization of malignancy, but characterization was limited for hypervascular nodules 2 cm or less in diameter.

Intrahepatic peripheral cholangiocarcinoma (IPCC): comparison between perfusion ultrasound and CT imaging

PurposeThis study was done to compare the perfusion patterns of intrahepatic peripheral cholangiocarcinoma (IPCC) on contrast-enhanced ultrasound (CEUS) and dynamic computed tomography (CT).Materials and methodsWe retrospectively reviewed 23 histologically proven cases of IPCC. All lesions were studied by CEUS with sulfur hexafluoride-filled microbubbles coated with a phospholipid capsule, and by dynamic CT. Contrast-enhancement patterns were evaluated in the arterial phase (CEUS 10–20 s after the injection; CT 25–30 s after the injection) and in the delayed phase (CEUS 120 s after the injection; CT>2–3 min after the injection).ResultsLesions were single in 18/23 cases (78%), single with nearby satellite lesions in 1/23 (4%) cases and multifocal with distant secondary lesions in 4/23 (17%) cases. Lesion diameter was 2–5 cm in 7/23 cases (30%), 5–7 cm in 13/23 cases (57%) and >7 cm in 3/23 (13%) cases. On CEUS, lesions were hypervascular in 16/23 cases (70%). On delayed-phase CEUS, 22/23 lesions (96%) were markedly hypoechoic. CT showed that the lesions were hypovascular in the arterial phase in 15/23 cases (66%) and hypervascular in 7/23 (30%) cases; one lesion (1/23; 4%) was isovascular. On delayed-phase CT, lesions were hyperdense in 17/23 cases (74%), hypodense in 5/23 (22%) cases and isodense in 1/23 (43%) cases.ConclusionsEnhancement discrepancy between delayed-phase CEUS (hypoechogenicity) and CT (hyperdensity) is common semiological findings in the study of IPCC.RiassuntoObiettivoConfrontare le caratteristiche perfusionali del colangiocarcinoma intra-epatico periferico (IPCC) in ecografia con mdc (CEUS) e TC dinamica.Materiali e metodiAnalisi retrospettiva di 23 casi di colangiocarcinoma periferico istologicamente accertati. Tutte le lesioni sono state studiate con CEUS utilizzando microbolle a base di esaflururo di zolfo ricoperte da una capsula di fosfolipidi quale mezzo di contrasto e con TC dinamica. Sono state valutate le caratteristiche della impregnazione lesionale nelle fasi arteriosa (CEUS: 10–20 s dopo l’iniezione; TC: 25–30 s dopo l’iniezione) e tardiva (CEUS: 120 s dopo l’iniezione; TC>2–3 min dopo l’iniezione).RisultatiIn 18/23 (78%) la lesione era singola, in 1/23 (4%) singola con lesioni satelliti a ridosso della lesione principale e in 4/23 (17%) multifocale con lesioni a distanza rispetto alla lesione prinicipale. Le dimensioni delle lesioni erano comprese tra 2 e 5 cm di diametro in 7/23 (30%), tra 5 e 7 cm in 13/23 (57%) e superiori a 7 cm in 3/23 (13%). La CEUS ha evidenziato ipervascolarizzazione delle lesioni in 16/23 (70%). Ventidue su 23 lesioni (96%) in fase tardiva CEUS, sono risultate marcatamente ipoecogene. La TC ha evidenziato ipovascolarizzazione delle lesioni in fase arteriosa in 15/23 (66%) ed ipervascolarizzazione in 7/23 (30%); una lesione (1/23; 4%) era isovascolarizzata. In fase tardiva TC la lesione era iperdensa in 17/23 (74%) casi, ipodensa in 5/23 (22%) e isodensa in 1/23 (43%) casi.ConclusioniIl riscontro di una discordanza di enhancement in fase tardiva tra CEUS (ipoecogenicità) e TC (iperdensità) rappresenta frequente rilievo semeiologico nello studio del colangiocarcinoma intraepatico periferico.

Ultrasonography of the pancreas. 7. Intraoperative imaging

The usefulness of intraoperative ultrasonography (IOUS) has been documented in the Literature since the Eighties and, although its main applications are in hepatobiliary and pancreatic surgery, it has been used also in neurosurgery, cardiovascular and endocrine surgery. The continuous technical developments have led to an increase in the diagnostic accuracy of IOUS from the Eighties to now. The use of IOUS has increased in time together with the technical innovations until, mainly in the mid-Nineties, its value was recognized by many surgeons. This results have been obtained with scanners that allow to depict fine anatomical details and detect small lesions in real time with extremly high spatial resolution. IOUS is able to shows fine details, such as primary or secondary lesions not detectable with other preoperative imaging modalities or tumor extension and its relationship with vessels [14, 15]. Assessment of resectability by IOUS may determine important changes in therapeutic planning [13, 14, 16–18]. The role of IOUS, however, has recently been downsized, especially in those centers where preoperative imaging is advanced [20, 21]. This article will review the clinical role of pancreatic IOUS in the different pancreatic pathologies.

Contrast-enhanced ultrasonography of small solid pseudopapillary tumors of the pancreas: enhancement pattern and pathologic correlation of 2 cases.

The purpose of this series is to describe the value of contrast‐enhanced ultrasonography (CEUS) in the characterization of small pseudopapillary tumors (SPTs) of the pancreas.

Increased fronto-temporal perfusion in bipolar disorder

OBJECTIVES Previous imaging reports showed over-activation of fronto-limbic structures in bipolar patients, particularly in response to emotional stimuli. In this study, for the first time, we used perfusion weighted imaging (PWI) to analyze lobar cerebral blood volume (CBV) in bipolar disorder to further explore the vascular component to its pathophysiology. METHODS Fourteen patients with DSM-IV bipolar disorder (mean age+/-SD=49.00+/-12.30 years; 6 males, 8 females) and 29 normal controls (mean age+/-SD=45.07+/-10.30 years; 13 males, 16 females) were studied. PWI images were obtained following intravenous injection of paramagnetic contrast agent (Gadolinium-DTPA), with a 1.5 T Siemens magnet using an echo-planar sequence. The contrast of enhancement (CE), was calculated pixel by pixel as the ratio of the maximum signal intensity drop during the passage of contrast agent (Sm) by the baseline pre-bolus signal intensity (So) (CE=Sm/So*100) for frontal, temporal, parietal, and occipital lobes, bilaterally, on two axial images. Higher CE values correspond to lower CBV and viceversa. RESULTS Bipolar patients had significantly lower CE values in left frontal and temporal lobes (p=0.01 and p=0.03, respectively) and significantly inverse laterality index for frontal lobe (p=0.017) compared to normal controls. No significant correlations between CE measure and age or clinical variables were found (p>0.05). CONCLUSION This study found increased left frontal and temporal CBV in bipolar disorder. Fronto-temporal hyper-perfusion may sustain over-activation of these structures during emotion modulation, which have been observed in patients with bipolar illness.

Detection of focal liver lesions: from the subjectivity of conventional ultrasound to the objectivity of volume ultrasound

PurposeThis study was undertaken to establish the reliability of automated volumetric liver scans in detecting focal liver lesions by evaluating the degree of agreement between conventional and volume ultrasound (US) examinations.Materials and methodsOver a period of 3 months, we prospectively studied 100 consecutive patients (36 men and 64 women; age range 15–87 years; mean age 63 years) referred to our institute for US imaging of the liver. Volumetric acquisition of the liver was achieved with a 3D transducer (2.0–5.0 MHz) and a Logiq 9 US scanner. All patients underwent both 2- and 3D US studies performed by two expert radiologists. Volumetric acquisitions were subsequently reviewed by the second radiologist, who was blinded to the first radiologist’s report. Three categories were established: 1=presence of focal liver lesions; 2=doubtful finding; 3=absence of focal liver lesions. Concordance between volume US and conventional US was calculated by using the k statistic.ResultsOut of 100 patients examined, 39 were found to be affected by focal liver lesions. All volume US examinations were technically adequate, allowing exploration of all hepatic sectors, except for five cases that were marred by major respiratory motion artefacts. Conventional and volume US identified the same number of focal liver lesions, with the exception of four cases of doubtful findings at volume US. Concordance between automated volume US and conventional US of the liver was high (k=0.92).ConclusionsThe identification of focal liver lesions on automated volume US is possible, and the examination shows a high level of concordance with conventional US.RiassuntoObiettivoStabilire l’affidabilità dell’acquisizione volumetrica automatica del fegato nell’identificazione delle lesioni focali epatiche, valutando la concordanza tra gli esami ecografici volumetrico e convenzionale.Materiali e metodiIn un periodo di tre mesi, sono stati studiati consecutivamente, in modo prospettico, 100 pazienti (36 uomini e 64 donne; range di età: 15–87 anni; media: 63 anni) giunti alla sezione di ecografia del nostro Istituto in regime di ricovero per eseguire un esame ecografico del fegato. L’acquisizione volumetrica del fegato è stata effettuata mediante sonda volumetrica (2,0–5,0 MHz) su ecografo Logiq 9. Gli esami ecografici, sia 2D che volumetrici, sono stati effettuati su tutti i pazienti da due radiologi esperti. È stata quindi successivamente effettuata una rilettura del volume dal secondo radiologo, all’oscuro del referto del primo. Sono state poi stabilite tre categorie: 1, presenza di lesioni focali; 2, dubbio di lesioni focali; 3, assenza di lesioni focali. La concordanza dell’acquisizione volumetrica con l’esame ecografico convenzionale è stata calcolata con il k test.RisultatiSu 100 pazienti studiati, in 39 sono state identificate lesioni focali epatiche. Tutti gli esami volumetrici sono risultati tecnicamente adeguati, in relazione alla esplorabilità ecografica di tutti i settori epatici, tranne 5 gravati da importanti artefatti da movimento respiratorio. Gli esami ecografici convenzionale e volumetrico hanno identificato lo stesso numero di lesioni focali epatiche, ad eccezione di 4 casi risultati dubbi per la presenza di lesione focale epatica all’esame ecografico volumetrico. La concordanza tra acquisizione volumetrica automatica del fegato ed esame ecografico convenzionale è risultata elevata (k=0,92).ConclusioniL’identificazione delle lesioni focali epatiche su acquisizioni volumetriche automatiche del fegato è possibile, risultando elevata la concordanza a tal fine dell’esame volumetrico ecografico rispetto all’esame ecografico convenzionale.

Identificazione delle lesioni focali epatiche: Dalla soggettività dell'esame ecografico convenzionale all'oggettività dell'esame ecografico volumetrico

PurposeThis study was undertaken to establish the reliability of automated volumetric liver scans in detecting focal liver lesions by evaluating the degree of agreement between conventional and volume ultrasound (US) examinations.Materials and methodsOver a period of 3 months, we prospectively studied 100 consecutive patients (36 men and 64 women; age range 15–87 years; mean age 63 years) referred to our institute for US imaging of the liver. Volumetric acquisition of the liver was achieved with a 3D transducer (2.0–5.0 MHz) and a Logiq 9 US scanner. All patients underwent both 2- and 3D US studies performed by two expert radiologists. Volumetric acquisitions were subsequently reviewed by the second radiologist, who was blinded to the first radiologist’s report. Three categories were established: 1=presence of focal liver lesions; 2=doubtful finding; 3=absence of focal liver lesions. Concordance between volume US and conventional US was calculated by using the k statistic.ResultsOut of 100 patients examined, 39 were found to be affected by focal liver lesions. All volume US examinations were technically adequate, allowing exploration of all hepatic sectors, except for five cases that were marred by major respiratory motion artefacts. Conventional and volume US identified the same number of focal liver lesions, with the exception of four cases of doubtful findings at volume US. Concordance between automated volume US and conventional US of the liver was high (k=0.92).ConclusionsThe identification of focal liver lesions on automated volume US is possible, and the examination shows a high level of concordance with conventional US.RiassuntoObiettivoStabilire l’affidabilità dell’acquisizione volumetrica automatica del fegato nell’identificazione delle lesioni focali epatiche, valutando la concordanza tra gli esami ecografici volumetrico e convenzionale.Materiali e metodiIn un periodo di tre mesi, sono stati studiati consecutivamente, in modo prospettico, 100 pazienti (36 uomini e 64 donne; range di età: 15–87 anni; media: 63 anni) giunti alla sezione di ecografia del nostro Istituto in regime di ricovero per eseguire un esame ecografico del fegato. L’acquisizione volumetrica del fegato è stata effettuata mediante sonda volumetrica (2,0–5,0 MHz) su ecografo Logiq 9. Gli esami ecografici, sia 2D che volumetrici, sono stati effettuati su tutti i pazienti da due radiologi esperti. È stata quindi successivamente effettuata una rilettura del volume dal secondo radiologo, all’oscuro del referto del primo. Sono state poi stabilite tre categorie: 1, presenza di lesioni focali; 2, dubbio di lesioni focali; 3, assenza di lesioni focali. La concordanza dell’acquisizione volumetrica con l’esame ecografico convenzionale è stata calcolata con il k test.RisultatiSu 100 pazienti studiati, in 39 sono state identificate lesioni focali epatiche. Tutti gli esami volumetrici sono risultati tecnicamente adeguati, in relazione alla esplorabilità ecografica di tutti i settori epatici, tranne 5 gravati da importanti artefatti da movimento respiratorio. Gli esami ecografici convenzionale e volumetrico hanno identificato lo stesso numero di lesioni focali epatiche, ad eccezione di 4 casi risultati dubbi per la presenza di lesione focale epatica all’esame ecografico volumetrico. La concordanza tra acquisizione volumetrica automatica del fegato ed esame ecografico convenzionale è risultata elevata (k=0,92).ConclusioniL’identificazione delle lesioni focali epatiche su acquisizioni volumetriche automatiche del fegato è possibile, risultando elevata la concordanza a tal fine dell’esame volumetrico ecografico rispetto all’esame ecografico convenzionale.

Detection of focal liver lesions: from the subjectivity of conventional ultrasound to the objectivity of volume ultrasound@@@Identificazione delle lesioni focali epatiche: dalla soggettività dell’esame ecografico convenzionale all’oggettività dell’esame ecografico volumetrico

PurposeThis study was undertaken to establish the reliability of automated volumetric liver scans in detecting focal liver lesions by evaluating the degree of agreement between conventional and volume ultrasound (US) examinations.Materials and methodsOver a period of 3 months, we prospectively studied 100 consecutive patients (36 men and 64 women; age range 15–87 years; mean age 63 years) referred to our institute for US imaging of the liver. Volumetric acquisition of the liver was achieved with a 3D transducer (2.0–5.0 MHz) and a Logiq 9 US scanner. All patients underwent both 2- and 3D US studies performed by two expert radiologists. Volumetric acquisitions were subsequently reviewed by the second radiologist, who was blinded to the first radiologist’s report. Three categories were established: 1=presence of focal liver lesions; 2=doubtful finding; 3=absence of focal liver lesions. Concordance between volume US and conventional US was calculated by using the k statistic.ResultsOut of 100 patients examined, 39 were found to be affected by focal liver lesions. All volume US examinations were technically adequate, allowing exploration of all hepatic sectors, except for five cases that were marred by major respiratory motion artefacts. Conventional and volume US identified the same number of focal liver lesions, with the exception of four cases of doubtful findings at volume US. Concordance between automated volume US and conventional US of the liver was high (k=0.92).ConclusionsThe identification of focal liver lesions on automated volume US is possible, and the examination shows a high level of concordance with conventional US.RiassuntoObiettivoStabilire l’affidabilità dell’acquisizione volumetrica automatica del fegato nell’identificazione delle lesioni focali epatiche, valutando la concordanza tra gli esami ecografici volumetrico e convenzionale.Materiali e metodiIn un periodo di tre mesi, sono stati studiati consecutivamente, in modo prospettico, 100 pazienti (36 uomini e 64 donne; range di età: 15–87 anni; media: 63 anni) giunti alla sezione di ecografia del nostro Istituto in regime di ricovero per eseguire un esame ecografico del fegato. L’acquisizione volumetrica del fegato è stata effettuata mediante sonda volumetrica (2,0–5,0 MHz) su ecografo Logiq 9. Gli esami ecografici, sia 2D che volumetrici, sono stati effettuati su tutti i pazienti da due radiologi esperti. È stata quindi successivamente effettuata una rilettura del volume dal secondo radiologo, all’oscuro del referto del primo. Sono state poi stabilite tre categorie: 1, presenza di lesioni focali; 2, dubbio di lesioni focali; 3, assenza di lesioni focali. La concordanza dell’acquisizione volumetrica con l’esame ecografico convenzionale è stata calcolata con il k test.RisultatiSu 100 pazienti studiati, in 39 sono state identificate lesioni focali epatiche. Tutti gli esami volumetrici sono risultati tecnicamente adeguati, in relazione alla esplorabilità ecografica di tutti i settori epatici, tranne 5 gravati da importanti artefatti da movimento respiratorio. Gli esami ecografici convenzionale e volumetrico hanno identificato lo stesso numero di lesioni focali epatiche, ad eccezione di 4 casi risultati dubbi per la presenza di lesione focale epatica all’esame ecografico volumetrico. La concordanza tra acquisizione volumetrica automatica del fegato ed esame ecografico convenzionale è risultata elevata (k=0,92).ConclusioniL’identificazione delle lesioni focali epatiche su acquisizioni volumetriche automatiche del fegato è possibile, risultando elevata la concordanza a tal fine dell’esame volumetrico ecografico rispetto all’esame ecografico convenzionale.