Giovanni Mauri

Pleural and Peripheral Lung Lesions: Comparison of US- and CT-guided Biopsy

PURPOSE To retrospectively compare the outcome of computed tomography (CT) and ultrasonography (US) guidance when sampling a consecutive series of peripheral lung or pleural lesions. MATERIALS AND METHODS Institutional review board approval was obtained, and the informed consent requirement was waived. From January 2000 to August 2011, 711 thoracic biopsies were performed at two institutions. Among these, 273 lesions in 273 patients (115 men, 158 women; mean age, 65 years ± 11 [standard deviation]; 86 pleural lesions; 187 pulmonary lesions) had pleural origin or were peripherally located in the lung with a small amount of pleural contact. These lesions were sampled with either CT (170 patients; mean age, 64 years ± 12; 55 pleural lesions, 115 peripheral pulmonary lesions) or US (103 patients; mean age, 67 years ± 10; 31 pleural lesions, 72 peripheral pulmonary lesions) guidance by using an 18-gauge modified Menghini needle. Procedure duration, postprocedural pneumothorax or hemorrhage, and sample adequacy were recorded. Fisher exact test, log-rank test, and Mann-Whitney U test were performed. RESULTS No significant difference was found for patient age (P = .741), sex (P = .900), lesion size (P = .206), or lesion origin (P = .788). Median time was 556 seconds for CT-guided biopsy (25th percentile, 408 seconds; 75th percentile, 704 seconds) and 321 seconds for US-guided biopsy (25th percentile, 157 seconds; 75th percentile, 485 seconds) (P < .001). Postprocedural pneumothorax was observed in 25 of 170 (14.7%) CT-guided procedures and in six of 103 (5.8%) US-guided procedures (P = .025); hemorrhage occurred in two of 170 (1.2%) CT-guided procedures and in one of 103 (1.0%) US-guided procedures (P = .875). Technical success was achieved in 100 of 103 US-guided procedures (97.1%) and in 164 of 170 CT-guided procedures (96.5%) (P = .999). CONCLUSION With pleural or peripheral lung lesions, US guidance is comparable to CT guidance in terms of sample accuracy, while allowing for a significant reduction in procedure time and postprocedural pneumothorax and being free from ionizing radiation.

Ultrasound guidance to perform intra-articular injection of gadolinium-based contrast material for magnetic resonance arthrography as an alternative to fluoroscopy: the time is now

Abstract Magnetic resonance (MR) imaging has been definitively established as the reference standard in the evaluation of joints in the body. Similarly, magnetic resonance arthrography has emerged as a technique that has been proven to increase significantly the diagnostic performance if compared with conventional MR imaging, especially when dealing with fibrocartilage and articular cartilage abnormalities. Diluted gadolinium can be injected in the joint space using different approaches: under palpation using anatomic landmarks or using an imaging guidance, such as fluoroscopy, computed tomography, or ultrasound. Fluoroscopy has been traditionally used, but the involvement of ionizing radiation should represent a remarkable limitation of this modality. Conversely, ultrasound has emerged as a feasible, cheap, quick, and radiation-free modality that can be used to inject joints, with comparable accuracy of fluoroscopy. In the present paper, we discuss the advantages and disadvantages of using fluoroscopy or ultrasound in injecting gadolinium-based contrast agents in joints to perform magnetic resonance arthrography, also in view of the new EuroSAFE Imaging initiative promoted by the European Society of Radiology and the recent updates to the European Atomic Energy Community 2013/59 directive on the medical use of ionizing radiation.Key Points• Intra-articular contrast agent injection can be performed using different imaging modalities• Fluoroscopy is widely used, but uses ionizing radiation• Ultrasound is an accurate, quick, and radiation-free modality for joint injection• X-rays should be avoided when other radiation-free modalities can be used

Ultrasound-guided procedures around the wrist and hand: How to do

Ultrasound has emerged as a low-cost, radiation-free and effective imaging technique to detect joint abnormalities and to guide percutaneous procedures. Being superficial, wrist and hand tendons and joints represent a good target to perform such procedures using ultrasound guidance. This kind of approach allows for a clear and real-time visualization of the needles during their whole path. In this setting, the knowledge of technical aspects and tips is essential to act in the most accurate way on target tissues that can be as small as a few millimetres. The aim of this review is to summarize the local treatments of inflammatory and degenerative disease described in literature (such as treatment of De Quervains tenosynovitis, trigger finger, trapezio-metacarpal joint osteoarthritis, etc.), emphasizing precautions and tricks based on day-by-day experience that may help to improve the outcome of percutaneous ultrasound-guided procedures around the wrist and hand.

Post-surgical enteric fistula treatment with image-guided percutaneous injection of cyanoacrylic glue

Post-surgical enteric fistula treatment with image-guided percutaneous injection of cyanoacrylic glue G. Mauri *, L.M. Sconfienza , B. Fiore , G. Brambilla , V. Pedicini , D. Poretti , R.F. Lutman , M. Montorsi , F. Sardanelli e a Facolt a di Medicina e Chirurgia, Scuola di Specializzazione in Radiodiagnostica, Universit a degli Studi di Milano, Italy Unit a di Radiologia, IRCCS Policlinico San Donato, Italy Dipartimento di Diagnostica per Immagini, IRCCS Istituto Clinico Humanitas, Italy Dipartimento di Medicina traslazionale, Universita’ degli Studi di Milano, IRCCS Istituto Clinico Humanitas, Rozzano, Italy Dipartimento di Scienze Medico-Chirurgiche, Unit a di Radiologia, Universit a degli Studi di Milano, IRCCS Policlinico San Donato, Milan, Italy

Technical success, technique efficacy and complications of minimally-invasive imaging-guided percutaneous ablation procedures of breast cancer: A systematic review and meta-analysis

ObjectivesTo systematically review studies concerning imaging-guided minimally-invasive breast cancer treatments.MethodsAn online database search was performed for English-language articles evaluating percutaneous breast cancer ablation. Pooled data and 95% confidence intervals (CIs) were calculated. Technical success, technique efficacy, minor and major complications were analysed, including ablation technique subgroup analysis and effect of tumour size on outcome.ResultsForty-five studies were analysed, including 1,156 patients and 1,168 lesions. Radiofrequency (n=577; 50%), microwaves (n=78; 7%), laser (n=227; 19%), cryoablation (n=156; 13%) and high-intensity focused ultrasound (HIFU, n=129; 11%) were used. Pooled technical success was 96% (95%CI 94–97%) [laser=98% (95–99%); HIFU=96% (90–98%); radiofrequency=96% (93–97%); cryoablation=95% (90–98%); microwave=93% (81–98%)]. Pooled technique efficacy was 75% (67–81%) [radiofrequency=82% (74–88); cryoablation=75% (51–90); laser=59% (35–79); HIFU=49% (26–74)]. Major complications pooled rate was 6% (4–8). Minor complications pooled rate was 8% (5–13%). Differences between techniques were not significant for technical success (p=0.449), major complications (p=0.181) or minor complications (p=0.762), but significant for technique efficacy (p=0.009). Tumour size did not impact on variables (p>0.142).ConclusionsImaging-guided percutaneous ablation techniques of breast cancer have a high rate of technical success, while technique efficacy remains suboptimal. Complication rates are relatively low.Key Points• Imaging-guided ablation techniques for breast cancer are 96% technically successful.• Overall technique efficacy rate is 75% but largely inhomogeneous among studies.• Overall major and minor complication rates are low (6–8%).

Identification of residual tumor with intraoperative contrast-enhanced ultrasound during glioblastoma resection.

OBJECTIVE The purpose of this study was to assess the capability of contrast-enhanced ultrasound (CEUS) to identify residual tumor mass during glioblastoma multiforme (GBM) surgery, to increase the extent of resection. METHODS The authors prospectively evaluated 10 patients who underwent surgery for GBM removal with navigated ultrasound guidance. Navigated B-mode and CEUS were performed prior to resection, during resection, and after complete tumor resection. Areas suspected for residual tumors on B-mode and CEUS studies were localized within the surgical field with navigated ultrasound and samples were sent separately for histopathological analysis to confirm tumor presence. RESULTS In all cases tumor remnants were visualized as hyperechoic areas on B-mode, highlighted as CEUS-positive areas, and confirmed as tumoral areas on histopathological analysis. In 1 case only, CEUS partially failed to demonstrate residual tumor because the residual hyperechoic area was devascularized prior to ultrasound contrast agent injection. In all cases CEUS enhanced B-mode findings. CONCLUSIONS As has already been shown in other neoplastic lesions in other organs, CEUS is extremely specific in the identification of residual tumor. The ability of CEUS to distinguish between tumor and artifacts or normal brain on B-mode is based on its capacity to show the vascularization degree and not the echogenicity of the tissues. Therefore, CEUS can play a decisive role in the process of maximizing GBM resection.

Ultrasound-guided interventional procedures around the shoulder

Ultrasound is an established modality for shoulder evaluation, being accurate, low cost and radiation free. Different pathological conditions can be diagnosed using ultrasound and can be treated using ultrasound guidance, such as degenerative, traumatic or inflammatory diseases. Subacromial-subdeltoid bursitis is the most common finding on ultrasound evaluation for painful shoulder. Therapeutic injections of corticosteroids are helpful to reduce inflammation and pain. Calcific tendinopathy of rotator cuff affects up to 20% of painful shoulders. Ultrasound-guided treatment may be performed with both single- and double-needle approach. Calcific enthesopathy, a peculiar form of degenerative tendinopathy, is a common and mostly asymptomatic ultrasound finding; dry needling has been proposed in symptomatic patients. An alternative is represented by autologous platelet-rich plasma injections. Intra-articular injections of the shoulder can be performed in the treatment of a variety of inflammatory and degenerative diseases with corticosteroids or hyaluronic acid respectively. Steroid injections around the long head of the biceps brachii tendon are indicated in patients with biceps tendinopathy, reducing pain and humeral tenderness. The most common indication for acromion-clavicular joint injection is degenerative osteoarthritis, with ultrasound representing a useful tool in localizing the joint space and properly injecting various types of drugs (steroids, lidocaine or hyaluronic acid). Suprascapular nerve block is an approved treatment for chronic shoulder pain non-responsive to conventional treatments as well as candidate patients for shoulder arthroscopy. This review provides an overview of these different ultrasonography-guided procedures that can be performed around the shoulder.

Percutaneous ablation holds the potential to substitute for surgery as first choice treatment for symptomatic benign thyroid nodules

We read with interest the letter by Tez M. regarding our article recently published in International Journal of Hyperthermia entitled “Benign thyroid nodules treatment using percutaneous laser ablation (PLA) and radiofrequency ablation (RFA)” [1]. In his letter, Tez underlines the increasingly important role of RFA in the treatment of recurrent thyroid cancers and benign thyroid nodules. However, it should be noticed that PLA also has been widely and successfully used in the treatment of both recurrent thyroid cancers and benign nodular nodules [2–4]; currently, no clear evidence of superiority of one technique over the other is present in literature. Particularly, when dealing with a complex anatomical region as the neck, the smaller calibre of laser fibres, and the more precise energy deposition seems to represent a theoretical advantage of this technique over RFA. Moreover, it is difficult to understand from the present literature how much the result of ablation is influenced by the ablative technology (e.g. PLA or RFA) and how much by other factors, such as the experience of the operator in performing ablations. Furthermore, the application of the most recent image guidance modalities such as fusion imaging and contrast enhanced ultrasound might also influence the result of the treatment regardless the ablative technology used [5–8]. Thus, the aim of our work was to compare percentage volume reduction over time in patients with benign thyroid nodule treated with PLA or RFA by the same operators and with the same procedural technique. This was done to limit confounding variables that could affect the comparison of the two ablative technologies. In this scenario, our study demonstrated that PLA and RFA provide similar results in terms of volumetric reduction at 1, 6 and 12 months and similar complication rates when performed by operators with the same experience and with the same technique. Next, Tez pointed out that the benign thyroid nodules may be treated by surgery or radioiodine. Surgery has historically been the best (and the only available) treatment option for symptomatic not-functioning nodules for a long time. However, open surgery has been largely supplanted by less invasive techniques in several field of medicine. Examples include coronary angioplasty and stenting, endovascular repair of aortic aneurysm, and image-guided liver and kidney tumour ablation. These procedures are often considered the first choice treatment rather than open surgery. Furthermore, it is our strong belief that the aim of the modern medicine should be not only to develop more effective technique for treating patients, but also to find treatments that are as minimally invasive as possible. This would allow not only to treat the relevant disease, but also to take care of the patient as a whole [9–11]. Particularly, in the treatment of benign thyroid nodules, percutaneous ablations have been largely demonstrated to achieve good control of compressive symptoms with very low complication rates, and provide the advantage of sparing the patient the invasiveness of standard surgery [3,12]. In our series, all the patients reported a clinically significant improvement in symptoms or cosmetic problems after the procedure, that was sustained up to one year. Further, Tez points out the reported risk of micropapillary thyroid carcinoma in the context of a multinodular goitre. This is a very well-known problem, but the best management of patients with multinodular goitre is still debated. Should we perform multiple fine needle aspiration of each single nodule in the patients with multinodular goitre in order to exclude the presence of an occult micropapillary tumour? Should we offer total thyroidectomy to all the patients with multinodular goitre, even if asymptomatic, as a micro-papillary tumour might be present? Notably, the real clinical implication of a micro-papillary thyroid carcinoma is still to be defined, as often these tumours will never progress during the life of a patient. Thus any kind of treatment might represent an overtreatment [13]. The problem of overtreatment of thyroid cancer is so relevant, that some authors have provocatively proposed to turn off US machines in order not to even detect not-palpable thyroid nodules [14]. Finally, Tez questioned the relevance of our study [1], as no predefined criteria for allocating patients to one treatment group or the other were defined. This is of course one of the major limitations of the present study, as is typical of retrospective series. The purpose of this report is to suggest the potential merits of a prospective trial, not to prove superiority of one treatment vs. the other. Prospective studies with randomisation of patients to PLA or RFA treatment would be necessary to further clarify the topic. To the best of our knowledge, our study is the first comparing the result of PLA and RFA when performed by the same operators with the same technique. Our study reported no significant difference in volume reduction over time between the two technologies, when the approach is identical between the two ablative methods. Design of future clinical trials should keep this concept in mind. To be specific, such trials might best be designed so that both methods are delivered by each participating investigator, using identical methods (e.g. same imaging device, etc.).

Compliance of the valsalva graft's pseudosinuses at midterm follow-up with cardiovascular magnetic resonance

BACKGROUND In previous studies, the Valsalva grafts compliance at the level of the Dacron pseudosinuses was found similar to that of normal sinuses shortly (2±1 months) after the operation. We sought to investigate with cardiac magnetic resonance the compliance of the Valsalva graft pseudosinuses at midterm follow-up. METHODS Seven patients (group A) and 7 age-matched controls (group B) were studied with steady-state free precession and phase-contrast cardiac magnetic resonance for aortic root and ascending aorta evaluation. Blood pressure was measured during phase-contrast acquisition to derive the following mechanical properties of the vascular prosthesis: pulsatility, compliance, distensibility, and elastic modulus. RESULTS Mean postoperative follow-up was 55±9.84 months. Mean age was 69.2±4.98 years in group A, and 65.7±7.16 years in group B. All the studied variables were coherent in showing a significant difference between the two groups, and between aortic root (skirt portion of the graft) and ascending aorta (tubular part of the graft) in group A. The presence of periaortic fibrosis did not show any correlation with the ascending aortas mechanical properties. CONCLUSIONS At midterm follow-up, the pseudosinuses compliance of the Valsalva graft is still appreciable and significantly greater than the tubular portion.

Dynamic high-resolution ultrasound of intrinsic and extrinsic ligaments of the wrist: How to make it simple

Wrist ligaments are crucial structures for the maintenance of carpal stability. They are classified into extrinsic ligaments, connecting the carpus with the forearm bones or distal radioulnar ligaments, and intrinsic ligaments, entirely situated within the carpus. Lesions of intrinsic and extrinsic ligaments of the wrist have been demonstrated to occur largely, mostly in patients with history of trauma and carpal instability, or rheumatoid arthritis. Ultrasound allows for rapid, cost-effective, non-invasive and dynamic evaluation of the wrist, and may represent a valuable diagnostic tool. Although promising results have been published, ultrasound of wrist ligaments is not performed in routine clinical practice, maybe due to its technical feasibility regarded as quite complex. This review article aims to enlighten readers about the normal sonographic appearance of intrinsic and extrinsic carpal ligaments, and describe a systematic approach for their sonographic assessment with detailed anatomic landmarks, dynamic manoeuvres and scanning technique.