Lucy E. Hann

Laparoscopic ultrasound enhances standard laparoscopy in the staging of pancreatic cancer.

OBJECTIVE To define the role of laparoscopic ultrasound (LUS) in the staging of pancreatic tumors. SUMMARY BACKGROUND DATA Laparoscopy has recently been established as a valuable tool in the staging of pancreatic cancer. It has been suggested that the addition of LUS to standard laparoscopy could improve the accuracy of this procedure. METHODS A prospective evaluation of 90 patients with pancreatic tumors undergoing laparoscopy and LUS was performed over a 27-month period. LUS equipped with an articulated curved and linear array transducer (6 to 10 MHz) was used. All patients underwent rigorous laparoscopic examination. Clinical, surgical, and pathologic data were collected. RESULTS The median age was 65 years (range 43 to 85 years). Sixty-four patients had tumors in the head, 19 in the body, and 3 in the tail of the pancreas. Four patients had ampullary tumors. LUS was able to image the primary tumor (98%), portal vein (97%), superior mesenteric vein (94%), hepatic artery (93%), and superior mesenteric artery (93%) in these patients. LUS was particularly helpful in determining venous involvement (42%) and arterial involvement (38%) by the tumor. This resulted in a change in surgical treatment for 13 (14%) of the 90 patients in whom standard laparoscopic examination was equivocal. CONCLUSIONS LUS is useful in evaluating the primary tumor and peripancreatic vascular anatomy. When standard laparoscopic findings are equivocal, LUS allowed accurate determination of resectability. Supplementing laparoscopy with LUS offers improved assessment and preoperative staging of pancreatic cancer.

What is the yield of intraoperative ultrasonography during partial hepatectomy for malignant disease

BACKGROUND Previous studies have shown that intraoperative ultrasonography (IOUS) during hepatic resection for malignancy changes the operative plan or identifies occult unresectable disease in a large proportion of patients. This study was undertaken to reassess the yield of IOUS in light of recent improvements in preoperative staging. STUDY DESIGN Patients with potentially resectable primary or metastatic hepatic malignancies subjected to exploration, bimanual palpation of the liver, and IOUS were evaluated prospectively. Intraoperative findings were recorded, and preoperative imaging studies were reanalyzed by radiologists blinded to the intraoperative findings. The extent of disease based on preoperative imaging was compared with the intraoperative findings. RESULTS From October 1997 until November 1998, 111 patients were evaluated. At exploration, a total of 77 new findings or findings different than suggested on the imaging studies were identified in 61 patients (55%), the most common of which was additional hepatic tumors (n = 37). Thirty-five of 77 (45%) new findings were identified by IOUS alone and 10 (13%) by palpation alone; the remainder were identified by both palpation and IOUS. Forty-seven of 61 patients (77%) underwent a complete resection despite new intraoperative findings, with a modification (n = 28) or no change (n = 19) in the planned operation. Twenty-one patients (19%) had new findings identified only on IOUS. Thirteen of these patients underwent resection with no change in the operative plan, six underwent a modified resection and two were considered to have unresectable disease based solely on the findings of IOUS. CONCLUSIONS In patients with hepatic malignancies submitted to a potentially curative resection, new intraoperative findings or findings different than suggested on preoperative imaging studies are common. But resection with no change in the operative plan or a modified resection is still possible in the majority of patients despite such findings. The findings on IOUS alone rarely lead to a change in the operative plan.

Polypoid Lesions of the Gallbladder: Diagnosis and Followup

BACKGROUND Polypoid lesions of the gallbladder (PLG) are commonly seen on ultrasonography (US), but optimal management of this problem is ill-defined. The aims of this study were to assess the natural history and the histologic characteristics of US-detected PLG. STUDY DESIGN Patients with PLG detected by abdominal US were identified retrospectively. Patients with infiltrative masses suspicious for gallbladder cancer were not included. Histologic findings were analyzed in patients who underwent cholecystectomy, and change in polyp size was determined in patients who underwent serial US imaging. RESULTS From 1996 through 2007, 417 patients with PLG detected on US were identified. Two hundred twenty-nine patients (55%) were women, and median age was 59 years (range 20 to 94 years). Two hundred sixty-five patients (64%) were found to have PLG on US during the workup of other unrelated disease; 94 patients (23%) had abdominal symptoms. Ninety-four percent of patients had PLG< or =10 mm, and 7% had PLG>10 mm; 59% of patients had a single polyp and 12% had gallstones. Among 143 patients who had repeat US followup, growth was observed in only 8 patients (6%). Cholecystectomy (n=80) revealed that most patients had either pseudopolyps (58%) or no polyp (32%). Neoplastic polyps (adenoma) were found in 10% of patients. In situ cancer was seen in one patient with a 14-mm lesion. CONCLUSIONS Small PLG (< or =10 mm in diameter) detected by US are infrequently associated with symptoms and can be safely observed. The risk of invasive cancer is very low, and was not seen in any patient in this study.

Gallbladder cancer : Can ultrasonography evaluate extent of disease?

This study reviews the spectrum of sonographic findings in patients with gallbladder cancer, attempts to determine if sonography can identify patients with potentially resectable disease, and emphasizes the limitations of ultrasonography in the evaluation of ‐gallbladder cancer. Thirty‐five consecutive patients with histologically proven gallbladder carcinoma who had preoperative abdominal ultrasonography and surgery were identified. Involvement of the gallbladder and gallbladder fossa, metastases, bile ducts, portal vein, and adjacent lymph nodes was assessed sonographically. The extent of disease and staging as revealed by sonography was compared to operative and surgical pathologic findings. Masses in the gallbladder or gallbladder fossa were present at surgery in 26 patients; 22 (85%) of these masses were shown by sonography. Sonography identified six (67%) of nine cases of pathologically confirmed liver metastases, 11 (79%) of 14 cases of bile duct involvement, and two (67%) of three cases of portal venous involvement by tumor. Sonography revealed lymph node metastases in only five (36%) of 14 patients. None of the 12 cases with peritoneal metastases was identified sonographically. By surgical staging 16 (46%) patients had potentially resectable disease (stage III or less), and 19 (54%) patients had unresectable stage IV disease. Sonography correctly identified 15 (94%) of 16 patients with potentially resectable disease and seven (37%) of 19 patients with advanced disease. Twelve patients with advanced disease were under‐staged: nine had peritoneal metastases, two had liver metastases, and one had celiac adenopathy, which was not shown by sonography. In conclusion, sonography is reliable in the detection of a primary gallbladder mass or of local extension of tumor into the liver. However, sonographic findings do not accurately reflect the full extent of disease, and sonography is particularly limited in the diagnoses of metastases to the peritoneum and lymph nodes.

Evaluation of Renal Masses With Contrast-Enhanced Ultrasound: Initial Experience

OBJECTIVE Nearly 25% of solid renal tumors are indolent cancer or benign and can be managed conservatively in selected patients. This prospective study was performed to determine whether preoperative IV microbubble contrast-enhanced ultrasound can be used to differentiate indolent and benign renal tumors from more aggressive clear cell carcinoma. SUBJECTS AND METHODS Thirty-four patients with renal tumors underwent preoperative gray-scale, color, power Doppler, and octafluoropropane microbubble IV contrast-enhanced ultrasound. Three blinded radiologists reading in consensus compared rate of contrast wash-in, grade and pattern of enhancement, and contrast washout compared with adjacent parenchyma. Contrast ultrasound findings were compared with surgical histopathologic findings for all patients. RESULTS The 34 patients had 23 clear cell carcinomas, three type 1 papillary carcinomas, one chromophobe carcinoma, one clear rare multilocular low-grade malignant tumor, two unclassified lesions, three oncocytomas, and one benign angiomyolipoma. The combination of heterogeneous lesion echotexture and delayed lesion washout had 85% positive predictive value, 43% negative predictive value, 48% sensitivity, and 82% specificity for predicting whether a lesion was conventional clear cell carcinoma or another tumor. Diminished lesion enhancement grade had 75% positive predictive value, 81% negative predictive value, 55% sensitivity, and 91% specificity for non-clear cell histologic features, either benign or low-grade malignant. Combining delayed washout with quantitative lesion peak intensity of at least 20% of kidney peak intensity had 91% positive predictive value, 40% negative predictive value, 63% sensitivity, and 80% specificity in the prediction of clear cell histologic features. CONCLUSION Ultrasound features of gray-scale heterogeneity, lesion washout, grade of contrast enhancement, and quantitative measure of peak intensity may be useful for differentiating clear cell carcinoma and non-clear cell renal tumors.

Sonographic Morphology of the Normal Menstrual Cycle

Sequential gray-scale sonograms were obtained during 20 menstrual cycles in 16 normal female volunteers. Hormonal and physical parameters of an ovulatory cycle were correlated with morphological changes in the ovaries, uterus, and cul-de-sac as seen on the sonogram. Ovarian cysts of two sizes were observed, corresponding chronologically and morphologically to Graafian follicles and corpora lutea. Small amounts of free pelvic fluid were demonstrated in many women at ovulation. A characteristic uterine appearance is seen prior to menstruation and is related to hormonal influences on the uterus. These findings emphasize the importance of recognizing normal physiological changes when interpreting gynecologic sonograms.

Deep venous thrombosis after orthopedic surgery in adult cancer patients

Background and Objectives: Patients with cancer and patients undergoing major orthopedic procedures are two groups at risk of deep venous thrombosis (DVT). The objective was to determine the rate of venous thromboembolic disease in patients with a malignant neoplasm and major orthopaedic surgery of the lower limb.

Implementation of Evidence-Based Guidelines for Thyroid Nodule Biopsy: A Model for Establishment of Practice Standards

OBJECTIVE Multiple studies have defined criteria for the selection of thyroid nodules for biopsy. No set of criteria is sufficiently sensitive and specific. The aim of this study is to develop a method for assessing consistency of practice in an ultrasound group and to determine whether a 5-point malignancy rating scale can be used to select patients for biopsy. MATERIALS AND METHODS One hundred one nodules (50 benign and 51 malignant) were selected from a thyroid biopsy database. Seven radiologists were educated on evidence-based criteria used to select nodules for biopsy. Using this information, readers graded the likelihood of malignancy using a 5-point malignancy rating scale, where 1 equals the lowest probability of malignancy and 5 equals the highest probability of malignancy, on the basis of overall impression of sonographic findings. Interobserver agreement on biopsy recommendation, reader sensitivity, specificity, and accuracy were determined. RESULTS The sensitivity and specificity of biopsy recommendation were 96.1% and 52%, respectively. The misclassification rate was 25.7%, and accuracy was 74.3%. Interobserver agreement on biopsy recommendation was fair to substantial (κ, 0.38-0.69). The proportion of agreement was excellent for malignant nodules (0.88-1.0). The risk of malignancy increased with increasing malignancy rating: 4.3% of nodules with a malignancy rating of 1 were malignant versus 93.4% of those assigned a rating of 5. CONCLUSION Our study illustrates a method to evaluate the standard of practice for thyroid nodule assessment among radiologists within an ultrasound group. Application of a 5-point malignancy rating scale to select nodules for biopsy is feasible and shows good diagnostic accuracy.

Proximal deep vein thrombosis after hip replacement for oncologic indications

BACKGROUND Patients with cancer who undergo surgery about the hip are at increased risk for the development of deep vein thrombosis. We implemented a program of chemical and mechanical prophylaxis to prevent this problem. This study was performed to assess the effectiveness of that program. METHODS Eighty-seven consecutive patients with an active malignant tumor who underwent hip replacement surgery at our institution over a two-year period were included in the study. All patients were treated with intermittent pneumatic compression devices. Seventy-eight patients received anticoagulants, and nine did not. Postoperative surveillance for proximal deep vein thrombosis was routinely performed on all patients with duplex Doppler ultrasonography. RESULTS Four patients had proximal deep vein thrombosis, and one patient, who did not receive anticoagulation, had a nonfatal pulmonary embolism. The use of prophylactic low-molecular-weight heparin (dalteparin) was associated with a 4% rate of proximal deep vein thrombosis (three of seventy-eight patients). Proximal deep vein thrombosis developed in three of eight patients with pelvic disease, one of nineteen patients with femoral disease, and zero of sixty patients with hip disease (p < 0.00001). The prevalence of proximal deep vein thrombosis was significantly higher (p < 0.02) following replacements in patients with sarcoma (three of twenty-one) than it was after replacements in patients with carcinoma (zero of fifty-seven) or hematologic malignant disease (one of nine). On multivariate analysis, only the location of the disease (the pelvis, femur, or hip) was found to be independently significant for an association with deep vein thrombosis. A wound complication developed in four of twenty-one patients with sarcoma and no patient with carcinoma or hematologic malignant disease (p < 0.001). The pathologic type was the only factor studied that was independently significant for an association with wound complications on multivariate analysis. CONCLUSIONS The rate of proximal deep vein thrombosis in patients who had undergone hip replacement for oncologic indications was low when the use of an intermittent pneumatic compression device was supplemented with prophylaxis with low-molecular-weight heparin.

Pre- and postmenopausal high-risk women undergoing screening for ovarian cancer: anxiety, risk perceptions, and quality of life.

OBJECTIVE Recommendations for women at high risk of ovarian cancer include prophylactic salpingo-oophorectomy (PSO) or screening with transvaginal ultrasonography (TVUS) and CA125 levels. The best strategy for improving survival and maintaining quality of life in high-risk women is not known. Premenopausal women may be more reluctant than postmenopausal women to undergo PSO. However, the risk of false-positive screening results may be more likely in premenopausal women, posing potential psychological risk for those enrolled in high-risk ovarian cancer surveillance programs. We sought to determine whether anxiety, depression, perception of ovarian cancer risk, and false-positive test frequency differed between high-risk premenopausal and postmenopausal women initiating ovarian cancer screening. METHODS High-risk women aged > or = 30 years enrolling in a TVUS plus CA125 ovarian cancer screening study completed standard QOL (SF-36), cancer-specific anxiety (IES), depression (CES-D), and ovarian cancer risk perception measures. CA125 > 35 and TVUS showing solid or complex cystic ovarian masses were considered abnormal. Abnormal tests were repeated after 4-6 weeks. Persistently abnormal tests prompted a search for malignancy. Tests that normalized on repeat were considered false positive. RESULTS One hundred forty-seven high-risk women, median age 46 (range, 30-78), 78 premenopausal and 69 postmenopausal, had > or = 1 TVUS/CA125/outcome assessment. Premenopausal women were more likely than postmenopausal women to consider themselves at higher risk of ovarian cancer compared with women their age (P < 0.001) and compared with women with similar family histories (P < 0.001). Mean personal perception of lifetime risk of ovarian cancer among premenopausal women was 37% (range, 0-90%) versus 26% (range, 0-60%) among postmenopausal women (P = 0.02). While general QOL and depression scores were similar, 38% of premenopausal women reported high anxiety versus 27% of postmenopausal women (P = 0.03). Thirty percent of women required repeat CA125 or TVUS after first screening; 10.8% of premenopausal women versus 4.6% of postmenopausal women required repeat CA125; and 23.3% of premenopausal and 20.6% of postmenopausal women required repeat TVUS. One postmenopausal woman with persistently rising CA125 >100 had negative mammography, colonoscopy, and dilation and curettage/bilateral salpingo-oophorectomy. All other abnormal tests normalized on repeat. Two premenopausal women withdrew due to anxiety following false-positive CA125 results. Five women (2 premenopausal, 3 postmenopausal) with normal TVUS/CA125 screening tests elected PSO, with benign findings. CONCLUSION Premenopausal women perceive their ovarian cancer risk to be higher, report greater ovarian cancer risk-related anxiety, and are more likely to have false-positive screening results than postmenopausal women. Few high-risk women elect PSO in the short term. Knowledge of the frequency of false-positive screening results and psychosocial outcomes is important for high-risk women choosing strategies for managing ovarian cancer risk.