Ferdinando D’Ambrosio

Ultrasound elastography in the evaluation of thyroid pathology. Current status

Thyroid pathology including thyroid nodules and diffuse thyroid diseases represents often a diagnosing challenge for clinicians. US, although highly accurate in identifying thyroid nodules and diffuse thyroid diseases, is still not sufficiently accurate to evaluate them. US-elastography has been introduced in order to further increase US accuracy in many fields and eventually for thyroid disease. The aim of the present paper it to provide an update of the literature on different available techniques and the results reported both for thyroid nodules differentiation and for diffuse thyroid disease evaluation. Advantages and limitations of elastography are also discussed.

Growing indications for CEUS: The kidney, testis, lymph nodes, thyroid, prostate, and small bowel

Contrast enhanced ultrasonography (CEUS) is increasingly used for non-hepatic applications as well, so that nearly all organs have been investigated. Among them, there is a growing clinical use for a variety of pathologies of the kidney, testis, and small bowel. The possibility to differentiate benign from malignant nodes in cancer patients has been investigated. A new application is in the detection of sentinel nodes after intradermal microbubble injection. The need to distinguish thyroid nodules eligible for fine needle aspiration cytology has led to the use of CEUS in thyroid examinations as well. The potential of CEUS for prostate cancer detection has been extensively investigated, with encouraging initial results. Early promise, however, has not been fulfilled. New perspective regards evaluation of the extent of prostate tissue devascularization following ablative treatments.

Prospective comparative evaluation of quantitative-elastosonography (Q-elastography) and contrast-enhanced ultrasound for the evaluation of thyroid nodules: Preliminary experience

PURPOSE To assess the effectiveness of semiquantitative elastosonography (Q-elastography) compared with contrast-enhanced ultrasound (CEUS) in differentiating the nature of thyroid nodules. METHODS AND MATERIALS Forty-eight consecutive patients (35 males, 13 females, range: 34-69 years, mean: 49.4 years), candidate to surgery, previously detected at color-Doppler ultrasound (CDUS), were prospectively examined with elastosonography with dedicated semiquantitative software (Q-Elastography, Toshiba XG) and CEUS (Technos Mylab 70 Gold X, and Toshiba XG) before surgery. CEUS and elastosonography were evaluated by two investigators in consensus. Comparison between the CEUS pattern and elastonographic strain ratio observed and expected frequencies for the diagnoses was evaluated with χ(2) test or with Fisher exact test. RESULTS Fifty-three nodules (19 papillary carcinoma, 32 hyperplasia, and 2 follicular adenoma) in 48 patients were available for analysis. Regarding echogenicity score, sensitivity, specificity, PPV and NPV of conventional US were 81%, 50%, 56%, 77%; according to Q-elastography, sensitivity, specificity, PPV and NPV were 95%, 88%, 97% and 91% respectively; whereas concerning CEUS, sensitivity specificity PPV and NPV were 79%, 91%, 83% and 89% respectively. Both CEUS and Q-elastography were more specific than US (p<0.01), with not statistical significant difference with regard to sensitivity. CONCLUSIONS The results of the present study suggest that Q-elastography is a valuable tool in the characterization of thyroid nodules and it seems to be more sensitive than CEUS.

Liver metastases: Contrast-enhanced ultrasound compared with computed tomography and magnetic resonance

The development of ultrasound contrast agents with excellent tolerance and safety profiles has notably improved liver evaluation with ultrasound (US) for several applications, especially for the detection of metastases. In particular, contrast enhanced ultrasonography (CEUS) allows the display of the parenchymal microvasculature, enabling the study and visualization of the enhancement patterns of liver lesions in real time and in a continuous manner in all vascular phases, which is similar to contrast-enhanced computed tomography (CT) and contrast-enhanced magnetic resonance imaging. Clinical studies have reported that the use of a contrast agent enables the visualization of more metastases with significantly improved sensitivity and specificity compared to baseline-US. Furthermore, studies have shown that CEUS yields sensitivities comparable to CT. In this review, we describe the state of the art of CEUS for detecting colorectal liver metastases, the imaging features, the literature reports of metastases in CEUS as well as its technique, its clinical role and its potential applications. Additionally, the updated international consensus panel guidelines are reported in this review with the inherent limitations of this technique and best practice experiences.

Update on ultrasound elastography: Miscellanea. Prostate, testicle, musculo-skeletal

Nowadays ultrasound elastosonography is an established technique, although with limited clinical application, used to assess tissue stiffness, which is a parameter that in most cases is associated with malignancy. However, although a consistent number of articles have been published about several applications of elastosonography, its use in certain human body districts is still not well defined. In this paper we write on the use of elastosonography in prostate, testicle and musculo-skeletal apparatus. We report and compare the work of several authors, different type of elastosonography (shear wave, strain elastography, etc.) and instrumental data obtained in the study of both benign and malignant lesions.

Differential diagnosis of endodontic- related inferior alveolar nerve paraesthesia with cone beam computed tomography: a case report

AIM To discuss the use of cone-beam computed tomography (CBCT) in the differential diagnosis of a case of labiomandibular paraesthesia caused by extrusion of endodontic sealer into the mandibular canal. SUMMARY A 59-year-old woman suffering from a paraesthesia on the left posterior mandible and numbness on the left side of the lower lip was referred to an endodontic specialist 1 month after multiple root canal treatments. A panoramic radiograph revealed the presence of extruded root filling material beyond the apex of the mesial root of the mandibular left second molar and also beyond the apex of the first premolar. A cone beam computed tomography examination was undertaken, which confirmed the presence of radiopaque root canal filling material in the periapical area of the second molar, and revealed that the material was inside the mandibular canal. No extruded filling material was found inside the mental foramen beyond the apex of the first premolar tooth. KEY LEARNING POINTS Small field of view CBCT (where possible) can be considered an effective radiographic diagnostic device when endodontic-related inferior alveolar nerve or mental foramen paraesthesia are suspected. CBCT is able to provide detailed three-dimensional images of the tooth, the root canal system and the surrounding tissue.

Ultrasound features of medullary thyroid carcinoma correlate with cancer aggressiveness: a retrospective multicenter study.

BackgroundPoor prognosis of medullary thyroid cancer (MTC) with suspicious ultrasound (US) features has been reported. The aim of the study was to investigate the association between preoperative US presentation and aggressiveness features of MTC. Also, US features of MTC were compared with those previously reported.MethodsStudy group comprised 134 MTC from nine different centers. Based on US presentation the nodules were stratified in “at risk for malignancy” (m-MTC) or “probably benign” (b-MTC) lesions.ResultsEighty nine (66.4%) m-MTC and 45 (33.6%) b-MTC were found. Metastatic lymph nodes (p = 0.0001) and extrathyroid invasiveness (p < 0.0001) were more frequent in m-MTC. There was statistically significant correlation (p = 0.0002) between advanced TNM stage and m-MTC with an Odds Ratio 5.5 (95% CI 2.1–14.4). Mean postsurgical calcitonin values were 224 – 64 pg/ml in m-MTC and 51 – 21 in b-MTC (p = 0.003).ConclusionsThis study showed that sonographically suspicious MTC is frequently associated with features of aggressiveness, suggesting that careful preoperative US of MTC patients may better plan their surgical approach.

Ultrasonography scoring systems can rule out malignancy in cytologically indeterminate thyroid nodules

PurposeTo assess the accuracy and reproducibility of ultrasonography classification systems in characterizing cytologically indeterminate thyroid nodules.MethodsWe retrospectively identified 49 nodules that had been surgically resected owing to features classified as indeterminate according to 2010 Italian Consensus on Thyroid Cytology criteria. Three experienced sonographers independently reviewed original sonographic images of each nodule and classified it using the 2015 American Thyroid Association (ATA) guidelines and the Thyroid Imaging Reporting and Data System (TI-RADS) classification proposed by Korean radiologists; later, images were reviewed jointly to obtain consensus classifications of each nodule. Original cytology slides were similarly reviewed by three experienced cytopathologists, who reclassified the nodule (independently, then jointly) according to revised Italian Consensus on Thyroid Cytology (ICTC-2014) criteria. Consensus ICTC-2014, ATA, and TI-RADS classifications were analyzed against surgical histology reports to estimate each system’s sensitivity, specificity, positive and negative predictive values.ResultsOf the 49 indeterminate nodules examined, 30 (61.2 %) were histologically benign. Consensus ICTC-2014 classification correctly classified malignant nodules with positive predictive value of 50 % and negative predictive value of 90 %. Sonographic classification of nodules as intermediate to high suspicion by ATA or TI-RADS category 4c displayed positive predictive value of 63 and 71 %, respectively; positive predictive values dropped to 44 and 42 % when lower positivity thresholds were used (ATA low suspicion, TI-RADS category 4a). Negative predictive values for ATA and TI-RADS were 91 and 74 %, respectively, with higher positivity thresholds and 100 % for both with lower thresholds. All systems displayed appreciable inter-observer variability (Krippendorff alphas: ATA 0.36, TIRADS 0.42, ICTC-2014 0.74).ConclusionsWith stringent negativity cut-offs, American Thyroid Association and Thyroid Imaging Reporting and Data System assessment of cytologically indeterminate thyroid nodules allows high-confidence exclusion of malignancy.

Recall strategies for patients found to have a nodule in cirrhosis: is there still a role for CEUS?

Development of liver tumors and their evolution to hepatocellular carcinoma (HCC) is a multi-step process in which different HCC-etiologies induce continuous rounds of hepatocyte damage and regeneration. Over an extended time, this triggers cirrhosis which is a pathological state of the liver in which lesions can progress to become dysplastic nodules. Later, these nodules may evolve into HCC and occasionally generate metastatic events. To provide optimal care, patients with liver cancer should be managed using a multidisciplinary approach in specialized centers in which all the diagnostic and therapeutic resources are available. Among the different imaging modalities the introduction on contrast agents for ultrasound use has opened new further applications in different clinical settings. In fact, contrast enhanced ultrasound (CEUS) has been applied for more than ten years and plays increasingly important roles in the management of HCC. Since early 2000, international societies including the American Association for the Study of Liver Diseases (AASLD), the European Association for the Study of the Liver (EASL), the Asian Pacific association for the Study of the Liver (APASL), the Japanese society of Hepatology (JSH), the Italian society for the study of the liver (AISF), the World Federation for Ultrasound in Medicine and Biology (WFUMB), and the European Federation of Societies for Ultrasound in Medicine and Biology (EFUSMB) have discussed the important role of CEUS in the diagnosis of HCC. In the present review an update of the literature and a detailed discussion of the present Guidelines regarding the role of CEUS in the evaluation of nodules in cirrhotic patients is offered.

Detection of small testicular masses in monorchid patients using US, CPDUS, CEUS and US-guided biopsy

PurposeTestis sparing surgery (TSS) is a well-known technique in the treatment of small testicular masses. Grayscale ultrasound (US), color/power Doppler US (CPDUS) and contrast-enhanced ultrasound (CEUS) are considered the best diagnostic imaging tools in those patients. Aim of this study was to assess the role of US imaging in the detection of small testicular masses in monorchid patients after orchiectomy for malignant neoplasm, and in guiding surgery to reach the target and also to differentiate lesions which presented vascular activity within the mass.MethodsFrom January 2011 to October 2014, 18 patients were enrolled in this study. They had previously undergone orchiectomy and were investigated for suspected contralateral disease. During routine follow-up, all patients underwent grayscale US. If findings were positive, CPDUS and CEUS were performed and eventually all patients underwent surgery. After exteriorization of the testis, the small mass was identified by intraoperative US, and a needle was placed under US guidance. After excision of the mass, frozen section examination was performed. When malignancy was found, radical orchiectomy was performed; if histological outcome was negative, the healthy testis was conserved.ResultsAll patients underwent grayscale US examination, which showed small hypoechoic masses. Each mass identified at US imaging was confirmed at surgery. All patients underwent CPDUS; 12/19 lesions showed blood flow while 7/19 showed absence of blood flow. At CEUS, 16/19 lesions showed enhancement and subsequent histological examination revealed that 8 were seminomas and 3 were Leydig cell tumors. In 5/19 cases CEUS showed the presence of lesions (focal inflammatory lesions) and in 3/19 cases CEUS was negative.ConclusionsTSS in monorchid patients may be a safe procedure leading to excellent results. We therefore consider it a valid alternative to radical orchiectomy, and US imaging is essential to guide the resection of non-palpable neoplasms and to exclude concomitant lesions.RiassuntoScopoLa testis sparing surgery (TSS) è una tecnica ben nota nel trattamento di piccole masse testicolari. L’ecografia in scala di grigi (US), il color/power Doppler (CPDUS) e l’ecografia con mezzo di contrasto (CEUS) sono considerati i migliori strumenti di diagnostica per immagini in questi pazienti. Scopo di questo studio è stato quello di valutare il ruolo dell’imaging ecografica nell’individuazione delle piccole masse testicolari nei pazienti monorchidi dopo orchiectomia per neoplasia maligna, nel ruolo di guida durante l’intervento chirurgico e nella differenziazione delle lesioni che presentavano attività vascolare dentro la massa.MetodiDa Gennaio 2011 a Novembre 2014, 18 pazienti (19 lesioni), orchiectomizzati per neoplasia, durante il follow-up di routine, sono stati sottoposti a ecografia. Se positivi, venivano sottoposti a CPDUS e CEUS ed ad intervento chirurgico. La piccola massa, era identificata e sotto guida ecografica marcata con ago. Dopo l’asportazione della massa, è stato eseguito l’esame istologico estemporaneo. In caso di malignità, veniva eseguita una orchiectomia radicale; se l’esito istologico era negativo, il testicolo sano veniva conservato.RisultatiIn tutti i pazienti l’ecografia ha mostrato 19 piccole masse ipoecogene confermate all’intervento chirurgico. Al CPDUS; 12/19 hanno mostrato presenza di flusso ematico, 7 hanno mostrato assenza di segnale. Alla CEUS, 16/19 sono risultate positive e l’esame istologico ha dimostrato 8 seminomi, 3 tumori a cellule di Leydig. In 5 casi la CEUS ha mostrato la presenza di lesioni (lesioni infiammatorie focali) e in 3 è stata negativa.ConclusioniLa TSS nei pazienti monorchidi può essere una procedura sicura che porta a eccellenti risultati. Tale tecnica può essere una valida alternativa all’orchiectomia radicale. L’imaging ecografico è essenziale per il riconoscimento e la caratterizzazione della lesione, per guidare la resezione delle neoplasie non palpabili e per escludere lesioni concomitanti.