Francesco Maria Solivetti

The association of colour flow doppler sonography and conventional ultrasonography improves the diagnosis of thyroid carcinoma

Objective: In the present study, we compared the results of conventional ultrasonography (US) and colour flow Doppler sonography (CFDS) with those of US guided fine needle aspiration biopsy (FNAB) and of pathologic staging of resected thyroid nodules, to assess the relative importance of US and CFDS in discriminating malignant thyroid nodules. Subjects and Study Design: We retrospectively reviewed records of 230 patients submitted to US-guided FNAB before surgery for solitary, not hot thyroid nodules. Before US guided FNAB, they were examined with conventional US and CFDS. Conventional US evaluated nodule size, echogenicity, presence of halo sign and microcalcifications. CFDS evaluated the vascular pattern classified as types I, II and III. Twenty-seven patients with inadequate cytology were excluded from this study (11.7%). Results: Two hundred and three patients underwent surgery. At histology a thyroid carcinoma was found in 36 patients (17.7%) and a benign nodule was observed in 167 patients (82.3%). We did not find any difference in cancer prevalence between nodules with a primary tumour size ≤1 cm and those >1 cm (17.6 vs. 17.7%; p = 0.99). A solid echo texture was not statistically significant to suggest malignancy (p = 0.32). Microcalcifications were seen in 83.3% (30/36) of malignant nodules and in33.5% (56/167) ofbenign nodules. These results were statistically significant (p < 0.0001). The type III flow as determined by CFDS was a statistically significant criterion to suggest malignant disease (p < 0.005). The most predictive findings of malignancy on conventional US was the combination of microcalcifications plus the absence of halo sign (sensitivity 75%, specificity 71.9%, p < 0.0001). The combination of an absence of halo sign on conventional US and a type III pattern on CFDS presented the higher sensitivity (83.3%) for malignancy with a specificity of 43.7%. Microcalcifications on US in combination with a type III CFDS pattern showed a lesser sensitivity (80.6%) with an improved specificity (75.4%). In our opinion, the better balanced combination of US and CFDS features was the absence of halo sign plus microcalcifications and a type III CDFS pattern (sensitivity 72.2%, specificity 77.2%). Conclusions: The combination of conventional US and CFDS provides benefits in increasing the screening sensitivity and accuracy in distinguishing malignant thyroid nodules.

Epithelioma of Malherbe: new ultrasound patterns

BackroundCalcifying epithelioma of Malherbe, or Pilomatricoma, is considered an uncommon cutaneous neoplasia, normally occurring in children as a solitary, firm, asymptomatic, hard, subcutaneous, slowly growing nodule on the face, neck, or proximal upper extremity. In literature, two Pilomatricoma ultrasound patterns are described: the totally calcified nodule and the hypoechoic nodule with internal calcific foci. High frequency ultrasound has not yet been applied for routine diagnosis of Pilomatricoma. The aim of the study was to retrospectively identify specific ultrasound features.MethodsWe retrieved 124 histologically Pilomatricoma cases: 28 patients with 32 lesions were preoperatively evaluated with ultrasound.Results22/32 have shown a solid formation, hypoechoic, with a sharp outline. Of these 22, 10 lesions were completely calcifying and 12 partially calcified. In 3/32 lesions with uncertain diagnosis, ultrasounds showed a complex/mixed pattern with pseudo-fluid areas and microspots. 7/32 lesions with US different diagnosis included 3 complex lesions, 2 cystic lesions and 2 solid nodular lesions.ConclusionIn addition to well-known ultrasound patterns (completely calcified and partially calcified) we identified three new, not yet described, patterns that constitute the 31% of the cases: complex, pseudocistyc and pseudotumoral.

Role of contrast-enhanced ultrasound in early diagnosis of psoriatic arthritis

Background: Radiographic examination (Rx) is still the best method to obtain an accurate diagnosis of psoriatic arthritis (PsA). Nevertheless, ultrasound (US) examination of the potentially involved joints has started to play a leading role. The sensitivity and specificity of a scan can be determined by contrast enhancement in the diagnosis of arthritis during PsA in comparison with basal US with MRI. Methods: Our study was made on 22 uninformed patients showing clinical suspicion of PsA. The patients were submitted to clinical evaluation, Rx, US with and without contrast enhancement and MRI. The parameters evaluated by basal US were effusion, synovial hypertrophy, positiveness to color power Doppler signals and bone erosion. Results: Contrast-enhanced US (CEUS) seems to amplify small alterations previously detected by US and, moreover, increases the diagnostic confidence in cases of suspected symptomatology with a negative diagnosis. Finally, CEUS appears to have a concordance of almost 100% with the results of MRI with contrast enhancement. Conclusion: US appears to be an effective method for detecting the alterations in bone outline and soft tissues, such as synovitis. Furthermore, US provides useful information concerning the evolution of vascularization and the dynamic behavior of tendons.

The diagnosis of early psoriatic arthritis in an outpatient dermatological centre for psoriasis

Background  Most of the data currently available on early psoriatic arthritis (EPsA) derive from studies performed in rheumatological settings. However, in recent years, there has been an increase in the amount of data from dermatologic centres.

Elastofibroma dorsi : histologic and echographic considerations

Background  Elastofibroma dorsi is a relatively rare soft‐tissue tumor of the elderly with typical localization to the subscapular area. To date, few cases have been reported in the dermatology literature. The differential diagnosis includes frequently observed subcutaneous neoplasms such as lipoma, fibrolipoma or more aggressive tumors. The diagnosis is made with histologic examination.

Effective treatment of Kaposi's sarcoma by electrochemotherapy and intravenous bleomycin administration

The present prospective study was aimed at evaluating the long‐term efficacy of local electrochemotherapy (ECT) with the intravenous administration of bleomycin, on disease progression and viral activity in classic Kaposis sarcoma (cKS), a vascular tumor related to human herpes virus‐8 infection. Eighteen patients affected by isolate or multiple cutaneous lesions, refractory to conventional treatments, although in the absence of visceral involvement, were enrolled in a study. Follow‐up visits were performed after 4 weeks and every 6 months for up to 48 months. A more extensive exploration of the immunologic status as well as of virological parameters was performed in nine patients. The results showed a significant clinical improvement in all patients after 4 weeks. A complete regression was observed in 12 patients after the first ECT, while four patients required a second treatment on the residual lesions after 4 weeks from the first intervention. The positive outcome persisted during the subsequent clinical control visits. Two patients, that showed rapidly evolving did not improve and relapsed despite a second round of ECT treatment. Effective treatment was associated with the reduction of viral load to undetectable levels. These data support the conduct of larger studies directed at validating the efficacy of ECT as a first‐line therapy for cKS.

AIDS-Kaposi Sarcoma and Classic Kaposi Sarcoma: are different ultrasound patterns related to different variants?

BackgroundKaposi Sarcoma (KS) is a malignancy of endothelial skin cells with multifocal localization on the skin, lymph nodes and visceral organs. Although all clinical variants are associated with HHV-8 infection, specific differences in the clinical onset and in the natural history of AIDS-KS and Classic-KS have been described. The present randomised prospective-observational study aimed to investigate whether the ultrasound pattern and color Doppler flow imaging of vascularisation of skin lesions of patients with Classic KS (CKS) or AIDS-KS could provide useful information to the evaluation of clinical activity of the disease.MethodsCutaneous lesions of 24 patients with histologically confirmed KS were investigated using very high frequency ultrasound probes; 16 patients had CKS and 8 had AIDS-KS. HHV-8 infection was confirmed in all patients by investigating the specific humoral response to viral antigens. Immunological and virological parameters were also assessed to monitor HIV or HHV-8 viral infection. For each patient, a target skin lesion was selected on the basis of size (diameter from 0.4 to 2 cm). Each lesion was analyzed in terms of size, depth and color Doppler pattern.ResultsThe B-mode ultrasound patterns of skin lesions did not differ when comparing CKS patients to AIDS-KS patients, whereas the color Doppler signal, which is associated with vascular activity, was detected in the KS lesions of 6/8 AIDS-KS patients (75.0%) and in 2/16 CKS (16,7%); the latter two patients showed a clinically progressive and extensive disease stage (IV B).ConclusionsOur preliminary results suggest that small cutaneous KS lesions - in both CKS and AIDS-KS patients- display similar B-mode ultrasound patterns ( hypoechoic, well defined, superficial lesions). However, the color Doppler signal, which is associated with endothelial activity and angiogenesis, which play a substantial role in KS progression, could constitute a useful tool for evaluating disease activity.

Ultrasound morphology of inguinal lymph nodes may not herald an associated pathology

BackgroundAmong patients undergoing follow-up after surgery for melanoma, ultrasound (US) very often reveals lymph nodes in groin area, that do not show clear characters of a metastatic lesion yet that have atypical US features, which could result in diagnostic uncertainty. We evaluated such lesions among a cohort of patients.MethodsThe study population consisted of patients who presented consecutively to our facility for a control between 1 January 2009 and 30 July 2010 and who had undergone surgery for a melanoma, at least 6 months earlier, in areas draining to lymph nodes of the groin but choosing – for this study - the opposite side to the natural drainage. The following parameters of the US performed on the lymph nodes were evaluated: number and size, aspects of the outline, including any extroflexion of the outline and contours morphology, homogeneity and thickness of the cortex and aspects of the hilus, characteristics of the vascularisation of the lymph node at color-power Doppler. A second US examination was performed on the same area after at least 12 months.Results and conclusionsWe found a very high number of patients (42/124) with lymph nodes that did not appear to be fully normal at US examination, particularly those with structural alterations in the hilus and slight loss of physiologic curvature of the outlines, with moderate thickening of the cortex. Of the 124 patients, who were followed for at least one year, 42 showed these characteristics, and none of these showed any progression to malignancy at follow-up. Based on these results, we can conclude that focusing excessively on such US findings could lead to the inappropriate performance of additional diagnostic tests, with a consequent increase in management costs and a worsening of the quality of life for these patients.

HF ultrasound vs PET-CT and telethermography in the diagnosis of In-transit metastases from melanoma: a prospective study and review of the literature

BackgroundOver the past several years the incidence of cutaneous melanoma has rapidly increased. This tumor develops often in-transit metastases that significantly reduce patient survival at 5 years. To improve prognosis and quality of life in patients with melanoma metastases, a mini invasive procedure like electrochemotherapy (ECT) is adopted to remove superficial tissue lesions. To detect the melanoma metastases, high frequency (HF) ultrasound (US) is used. This technique, though, can be time-consuming and it needs an expert operator and a high performing machine. Therefore, we asked whether the US could be replaced or integrated with other less time-consuming techniques such as 18-FDG positron emission tomography/computed tomography (PET-CT) and telethermography (TT).MethodsFifteen patients (4 males and 11 females - age range: 63–91) affected whit advanced stage melanoma were enrolled. They presented 52 in-transit metastases as detected by the three techniques used, HF-US, PET/CT and TT within 30 days before ECT.ResultsAll the 52 lesions were detected by HF-US (100%), 24/52 were detected by PET-CT (42,6%) and 15/52 were detected by TT (27,7%). PET-CT reported 3.7% false positives, while no false positive were reported by TT.ConclusionsAs US detected 100% lesions, compared to the other two techniques used, US, along with clinical examination, has still to be considered as gold standard in the diagnosis of metastatic lesions. US, associated with an exhaustive anamnesis and accurate clinical examination, cannot be replaced by either PET-CT or TT. When US performing devices and experienced operators are not available, though, it is highly recommended to integrate US with at least one of the other techniques. Under certain circumstances, as in the case of obese and non-collaborating patients or in patients with lymphatic stasis, these techniques should be integrated to obtain exact in-transit metastases evaluation.

Can video thermography improve differential diagnosis and therapy between basal cell carcinoma and actinic keratosis

Various noninvasive techniques (dermoscopy, confocal microscopy, etc.) have been introduced to help the clinical diagnosis in nonmelanoma skin cancer. Among them, the high definition video thermographic technique (VTG) has recently been proposed. The aim of this study is to define the VTG patterns, respectively of actinic keratosis (AK) and basal cell carcinoma (BCC), and to compare these data with them of dermoscopy. The study included 36 patients with a total number of 135 lesions who underwent clinical, VTG, and dermoscopic examination. The VTG showed the presence of a hyperthermic pattern in all the cases of AK, while in the case of the BCC, the pattern was hypothermic. Dermoscopy also showed distinct pattern for AK and for BCC, but in 22% of them the data were not conclusive. Our study permits us to define two specific VTG patterns, BCC and AK respectively.