Marco Sperandeo

Clinical application of transthoracic ultrasonography in inpatients with pneumonia

Eur J Clin Invest 2010; 41 (1): 1–7

Role of thoracic ultrasound in the assessment of pleural and pulmonary diseases

Although numerous studies have been conducted on the use of ultrasonography (US) for the examination of thoracic structures, this procedure is not as widely accepted as abdominal US. The newer portable scanners can be used at the bedside to detect pleural malignancies and effusions, as well as peripheral lung nodules of the lung, even in seriously ill patients. Focal thickening of the pleura can be easily detected with US and further investigated with a US-guided biopsy. US guidance can also be used during percutaneous drainage of pleural effusion or transthoracic biopsy of peripheral lung lesions, thus reducing the incidence of procedure-related pneumothorax to almost zero. We review the current literature on thoracic US and present our clinical experience with the technique in large groups of patients with pleural and peripheral lung diseases.

Transrectal Ultrasonography for the Early Diagnosis of Adenocarcinoma of the Prostate: A New Maneuver Designed to Improve the Differentiation of Malignant and Benign Lesions

PURPOSE Transrectal ultrasound can reveal potentially malignant prostate lesions while they are still small. However, based on ultrasound alone they are often difficult to distinguish from benign focal lesions. We tested the reliability of a new technique for the sonographic evaluation of typical prostate lesions in differentiating adenocarcinoma from benign lesions. MATERIALS AND METHODS During 18 months 398 consecutive male patients 45 to 76 years old underwent transrectal ultrasound for the early detection of prostate cancer. When suspicious hypoechoic lesions were noted in the peripheral regions of the prostate, moderate pressure was applied on the lesion using the ultrasound probe to evaluate consistency. Based on the response lesions were classified as deformable (the shape changed from approximately spherical to oval) or nondeformable (the original shape was retained). All lesions were then diagnosed based on fine needle biopsy. RESULTS Peripheral hypoechoic prostate lesions were sonographically identified in 146 of 398 patients (36.7%). In 68 cases nondeformable lesions proved to be adenocarcinoma in 63 (92.6%), and chronic prostatitis and/or adenomatous hyperplasia in 5. In contrast, 62 of the 78 deformable nodules (79.5%) showed histological features of hyperplasia and/or chronic inflammation. The remaining 16 nodules, which showed more limited changes in shape during compression, were characterized by hyperplasia with acute inflammatory changes. In 5 cases there was also evidence of adenocarcinoma. CONCLUSIONS Ultrasound guided compression of suspicious prostate lesions detected on transrectal sonography is a simple, rapid and reliable maneuver that may increase the diagnostic potential of this examination.

Assessment of ultrasound acoustic artifacts in patients with acute dyspnea: a multicenter study

Background Recent reports indicate that numerical assessment of B-lines during transthoracic ultrasound may aid the differential diagnosis of acute diffuse pleuropulmonary disorders. Purpose To determine whether B-lines are different in normal and diseased lungs and whether they can be used to discriminate between different types of pulmonary disorders in acutely ill patients. Material and Methods In this multicenter study, transthoracic ultrasonography was performed on 193 patients with acute dyspnea, 193 healthy non-smokers, and 58 patients who had undergone pneumonectomy for lung cancer. Examinations were done with a low–medium frequency (3.5–5.0 MHz) convex probe and a high-frequency (8–12.5 MHz) linear probe. Video recordings were re-examined by a second set of examiners. In each participant, we measured the number of B-lines observed per scan. Results B-lines counts were higher in dyspnoic patients (means: 3.11 per scan per linear probe scan vs. 1.93 in healthy controls and 1.86 in pneumonectomized patients; P < 0.001 for all); all counts were higher when convex probes were used (5.4 in dyspnoic patients and 2 in healthy controls; P < 0.001 vs. the linear probe). Subgroups of dyspnoic patients defined by cause of dyspnea displayed no significant differences in the number of B-lines. Conclusion Our results demonstrate that there are a significant higher number of B-lines in the lungs of patients with dyspnea compared to healthy subjects and to pneumonectomized patients. Nevertheless, the quantification of B-lines does not make any significant contribution to the differential diagnosis of dyspnea.

Molecular analysis of the HuD gene in neuroendocrine lung cancers

n-ELAV (neuronal-Embryonic Lethal, Abnormal Vision)-like genes belong to a family codifying for onconeural RNA-binding proteins, also called Hu antigens. Anti-Hu-antibodies (anti-Hu-Ab) are typically associated with paraneoplastic encephalomyelitis/sensory neuropathy (PEM/PSN), and low titres of anti-Hu-Ab were found in neural/neuroendocrine neoplasms, especially small cell lung cancer (SCLC). To date, few studies have been published focused on the genetic causes of their involvement in the pathogenesis of neuroendocrine tumors (NE). Here we analyzed 20 primary human neuroendocrine lung tumor tissues for somatic mutations in the HuD gene. Two inactivating mutations (a frameshift and a stop codon mutation) and 11 nucleotide changes were detected in the coding sequence of HuD gene in 7 different lung tumors. Our results on SCLC and carcinoid tissues support the hypothesis that alterations of nELAV genes could be involved in the onset and/or progression of a subset of neuroendocrine lung tumors.

Severe spontaneous acute tumor lysis syndrome and hypoglycemia in patient with germ cell tumor.

Tumor lysis syndrome has been observed in patients with bulky, treatment-sensitive tumors, in particular hematological malignancies, especially after medical treatment (chemotherapy, corticosteroids, radiation, hormonal agents, and biological response modifiers). Tumor lysis syndrome has been observed also in solid malignancies and it very rarely occurs spontaneously. Tumor lysis syndrome-associated metabolic abnormalities include hyperuricemia, hyperphosphatemia, hyperkalemia, hypocalcemia and uremia. Severe hypoglycemia is another rare metabolic disorder, uncommonly associated with solid malignancies. The case described here is peculiar for the abrupt onset of these two rare conditions in a patient with a metastatic germ cell tumor. Free full text available at www.tumorionline.it

Characterization of the normal pulmonary surface and pneumonectomy space by reflected ultrasound

Interest has been increasing in the use of transthoracic ultrasound for the study of the pleuropulmonary disease. US imaging depends mainly on the physical interactions between ultrasound waves and the tissues being examined. In the thoracic region, the prescence of the chest wall and the air-containing pulmonary tissues cause various artifacts that strongly influence the resulting images. At the interface between tissues and air, the ultrasound beam is totally reflected and produces simple reverberation, comet-tail artifacts, and ring-down artifacts.We report the findings of transthoracic ultrasound in normal healthy subjects and in those who had undergone pneumonectomy.This experience shows that, in terms of the ultrasound artifacts mentioned above, the postpneumonectomy cavity is not significantly different from the healthy lung.

Ultrasound signs of pulmonary fibrosis in systemic sclerosis as timely indicators for chest computed tomography

Objectives: Systemic sclerosis (SSc) patients in the early stages of pulmonary fibrosis (PF) often have few or no symptoms, normal to borderline pulmonary function tests, and negative chest X-ray (CXR); high-resolution computed tomography (HRCT) is the only reliable means of detecting the early signs of PF. However, thoracic ultrasound (TUS) enables detection of pleural thickening, pleural/subpleural nodules, and other subpleural lung abnormalities across 70% of the subpleural surface. We reassessed concordance between TUS abnormalities and HRCT findings in SSc patients, to see whether TUS pleural line thickness (normally < 3.0 mm) could be used to earmark those with asymptomatic PF for timely HRCT assessment. Method: In total, 175 SSc patients (nine males, 166 females), aged 46.46 ± 15.33 years, were given CXR, TUS, HRCT, echocardiography, and pulmonary function tests. Results: In the 26 patients without HRCT signs of PF, pleural line thickness was ≤ 3.0 mm. In diffuse SSc, 97/137 patients showed pleural line thickening (between 3.0 and 5 mm) and subpleural nodules in 32/97; and 35/137 showed major pleural line thickening (≥ 5.0 mm) with nodules, with good concordance with HRCT patterns indicating lung fibrosis severity. HRCT was normal in 5/137, with pleural line thickness ≤ 3.0 mm. Conclusions: TUS imaging of pleural/subpleural structures can detect ultrasonographic signs of initial PF prior to the onset of respiratory symptoms and function test abnormalities and, together with current criteria, could thereby enable exclusion of PF in SSc patients. Indicating some patients for selective referral to HRCT can thereby delay unwarranted procedures, provided that pulmonary function and TUS images are stable.

Optimization of Thoracic US Guidance for Lung Nodule Biopsy

We thank Dr Doss for his interest in our article. In the face of continuing controversy about the risks and benefits of CT (1,2), radiologists should continue to be mindful that even small amounts of radiation, delivered to a large population, might have harmful effects. Nevertheless, our study shows that, even in the face of worst-case LNT estimates, in a specific patient the real dangers of the underlying illness dwarf the risk of diagnostic CT radiation. We are in complete agreement with Dr Doss that patients should not be discouraged from undergoing appropriate diagnostic testing over a small risk, if any, of radiation-induced cancer.

Gene expression of somatostatin receptor subtypes SSTR2a, SSTR3 and SSTR5 in peripheral blood of neuroendocrine lung cancer affected patients

BackgroundSomatostatin (SS) acts as a universal endocrine off-switch, and also inhibits the growth of neuroendocrine tumours through its specific receptors (SSTRs). Somatostatin receptors are G-protein-coupled receptors, which are encoded by five separate genes (SSTR1-5). Short peptide analogues demonstrate specific binding only for the subgroup consisting of SSTR2a, SSTR3 and SSTR5. Moreover, previous studies reported that expression of mRNA for SSTR2a correlated with therapeutic outcome in patients with carcinoid tumours treated with somatostatin analogs.PurposeTo develop and apply a Real Time Quantitative PCR technique (RT-qPCR) to compare and contrast the mRNA levels of SSTR2a, SSTR3 and SSTR5 in Neuroendocrine Lung Cancer affected patients.MethodsPeripheral blood samples from 21 neuroendocrine lung cancer affected patients (14 SCLC, 6 LC and 1 LCNEC) subjected to scintigraphy with 111In-DTPA-D-Phe1-octreotide (OctreoScan) and 24 healthy blood donors were investigated by RT-qPCR. mRNA levels for SSTR2a, SSTR3 and SSTR5 were measured in peripheral blood samples with a relative quantification method using plasmid dilutions as calibration curves and GAPDH as reference gene.ResultsA statistically significant increase in target genes/GAPDH copy number ratio was found for SSTR2a (median 38; IQR 22–141) and SSTR5 (median 51; IQR 19–499) in neuroendocrine lung cancer affected patients as compared with samples from healthy blood donors (P ≤ 0.0003 and P ≤ 0.0005). Since low levels of expression were detected in the control group for all three genes, optimal cut-off values were assessed using ROC curve analyses and were equal to 9.05 for SSTR2a and 16.97 for SSTR5. These cut off values resulted in a sensitivity of 86% (95%IC 65–95) for both markers and a specificity of 83% (95%IC 64–93%) and 79% (95%IC 60–91%) for SSTR2a and SSTR5 respectively. Comparison between OctreoScan results and RT-qPCR analysis demonstrated agreement in 76% of the cases.ConclusionsOur results suggest that SSTR2a and SSTR5 mRNAs are detectable in peripheral blood of neuroendocrine lung cancer affected patients using real-time quantitative PCR, with a good agreement with OctreoScan. The high sensitivity of this non-invasive molecular technique suggests that this method could represent a useful tool in the clinical management of neuroendocrine lung cancers.