Michele Bertolotto

The EFSUMB guidelines and recommendations on the clinical practice of contrast enhanced ultrasound (CEUS): Update 2011 on non-hepatic applications

Authors F. Piscaglia1, C. Nolsøe2, C. F. Dietrich3, D. O. Cosgrove4, O. H. Gilja5, M. Bachmann Nielsen6, T. Albrecht7, L. Barozzi8, M. Bertolotto9, O. Catalano10, M. Claudon11, D. A. Clevert12, J. M. Correas13, M. D’Onofrio14, F. M. Drudi15, J. Eyding16, M. Giovannini17, M. Hocke18, A. Ignee19, E. M. Jung20, A. S. Klauser21, N. Lassau22, E. Leen23, G. Mathis24, A. Saftoiu25, G. Seidel26, P. S. Sidhu27, G. ter. Haar28, D. Timmerman29, H. P. Weskott30

Comparison of Contrast-Enhanced Sonography with Unenhanced Sonography and Contrast-Enhanced CT in the Diagnosis of Malignancy in Complex Cystic Renal Masses

OBJECTIVE The objective of our study was to evaluate contrast-enhanced sonography in the diagnosis of malignancy in complex cystic renal masses. MATERIALS AND METHODS We analyzed a series of 40 cystic renal masses (diameter, 2-8 cm) with a complex pattern at contrast-enhanced CT in 40 consecutive subjects (18 men, 22 women; mean age +/- SD, 62 +/- 11 years). Each renal mass was scanned using sonography without contrast material and after IV injection of sulfur hexafluoride-filled microbubbles during the arterial (15-40 seconds) and venous (40-120 seconds from injection) phases. Two radiologists in consensus assessed onsite the enhancement patterns in the peripheral wall and intracystic septa and the evidence of solid endocystic components. Three blinded readers with 2, 6, and 10 years of experience in renal imaging performed a retrospective off-site interpretation of unenhanced sonography, contrast-enhanced sonography, and CT images and made a benign or malignant diagnosis according to refer ence diagnostic criteria for contrast-enhanced sonography and to the Bosniak classification for CT. RESULTS Final diagnoses comprised two multilocular cystic nephromas, two inflammatory and seven hemorrhagic cysts, and eight uncomplicated benign cysts and 21 cystic renal cell carcinomas. The overall diagnostic accuracy of contrast-enhanced sonography was better than unenhanced sonography and CT (contrast-enhanced sonography vs unenhanced sonography vs CT: reader 1, 83% vs 30% vs 75%; reader 2, 83% vs 30% vs 63%; reader 3, 80% vs 30% vs 70%; p < 0.05, McNemar test). CONCLUSION Contrast-enhanced sonography was found to be better than unenhanced sonography and CT in the diagnosis of malignancy in complex cystic renal masses.

US and MR imaging of peripheral nerves in leprosy

Abstract Objective. To analyze peripheral nerves with ultrasonography (US) and magnetic resonance imaging (MR) in leprosy and assess the role of imaging in leprosy patients. Design and patients. Fifty-eight nerves with abnormal clinical features or electromyograms were examined in 23 leprosy patients by means of gray-scale US, Doppler US and MR imaging. Image analysis included: measurement of nerve cross-sectional area; assessment of nerve structure and MR signal intensities; identification of nerve compression within osteofibrous tunnels; detection of endoneural color flow signals and Gd-DTPA enhancement. Correlations were made with clinical findings and a control group of 20 subjects. Fourteen nerves in active reversal reaction were followed up after therapy. Results. Leprosy nerves were classified into three groups based on imaging appearance: group I consisted of 17 normal-appearing nerves; group II, of 30 enlarged nerves with fascicular abnormalities; group III, of 11 nerves with absent fascicular structure. Group II nerves were from patients subjected to reversal reactions; 75% of patients with group III nerves had a history of erythema nodosum leprosum. Nerve compression in osteofibrous tunnels was identified in 33% of group II and 18% of group III nerves. Doppler US and MR imaging were 74% and 92% sensitive in identifying active reactions, based on detection of endoneural color flow signals, long T2 and Gd enhancement. In 64% of cases, follow-up studies showed decreased color flow and Gd uptake after steroids and decompressive surgery. Conclusions. US and MR imaging are able to detect nerves abnormalities in leprosy. Active reversal reactions are indicated by endoneural color flow signals as well as by an increased T2 signal and Gd enhancement. These signs would suggest rapid progression of nerve damage and a poor prognosis unless antireactional treatment is started.

Characterization of unifocal liver lesions with pulse inversion harmonic imaging after Levovist injection: preliminary results

Abstract. The aim of this study was to evaluate capabilities of pulse inversion harmonic imaging (PIHI) in characterization of unifocal liver lesions. We evaluated with PIHI (HDI5000, ATL, Bothell, Wash.) and spiral CT 46 consecutive patients with a single liver lesion identified by fundamental US [7 hepatocellular carcinomas (HCC), 2 cholangiocarcinomas, 7 focal nodular hyperplasias (FNH), 17 hemangiomas and 13 metastases]. The PIHI was performed before and 30 s, 2 and 4 min after bolus administration of Levovist (2.5 g, 300 mg/ml). Scans were digitally stored and reviewed using a dedicated software. Hepatocellular carcinoma was hyperechoic on 30-s scan, and hypoechoic (n = 5) or isoechoic (n = 2) on 2-min scan. Cholangiocarcinoma had inhomogeneous persistent enhancement. Focal nodular hyperplasia was hyperechoic (n = 5) or isoechoic (n = 2) on 30-s scan, hyperechoic (n = 4), isoechoic (n = 2) or slightly hypoechoic (n = 1) on 2-min scan. Large hemangioma revealed peripheral enhancement on 30-s scan which extended centripetally on 2-min scan. Small hemangioma appeared isoechoic on 2-min scan in all but two cases in which they were hypoechoic on 2-min scans and hyperechoic on 4-min scan. Metastasis was hypoechoic on all scans, 70 % with rim enhancement. Similar changes in enhancement pattern have been observed at spiral CT.¶ The 30-s and the 2-min scans revealed a conclusive importance in characterization of HCC, cholangiocarcinoma, and large hemangioma. The 2-min scan often furnished enough information for characterization of small hemangioma and metastasis. The 4-min scan allowed characterization of two hemangiomas which appeared hypoechoic on 2-min scans. In the other cases it did not provide further information. Diagnosis of FNH is usually reached with Colour Doppler US; PIHI should be used when colour Doppler is biased by artefacts or when colour Doppler findings are not characteristic. Our results seem to show that PIHI could be a valuable alternative diagnostic approach to spiral CT for unifocal liver lesion characterization. This hypothesis needs to be confirmed with an increased number of lesions.

High-flow priapism: treatment and long-term follow-up

OBJECTIVES To determine the long-term follow-up of treatment of high-flow priapism, we reviewed the case records of 10 patients who were examined by the Urologic Clinic in Trieste from 1995 to 1998. High-flow or arterial priapism is a fairly rare dysfunction, generally resulting from penile or perineal trauma. In some cases, the etiology remains unknown. METHODS Trauma was reported in 6 of 10 cases. No etiologic causes were evident in the other patients. Nine patients underwent selective embolization during arteriography, and in 1 patient, corporotomy and ligature of the cavernous artery were performed. Color Doppler ultrasonography was repeated 1 day, 1 month, and 6 months after the operation. The determination of erectile function at a mean follow-up of 41 months (range 17 to 64) was performed using the International Index of Erectile Function. RESULTS Postoperatively, color Doppler ultrasonography revealed the absence of recurrence in 6 patients. Fistula recurrence was detected in 4 of 9 patients treated with selective embolization (44%). In three of these patients, a second embolization procedure was conclusive. In 1 case (11%), three consecutive embolizations were not conclusive and surgical ligature of the dorsal artery and collateral at the emergence of the penile root, out of the corpus cavernosum, was required. Sexual function was completely preserved in 80% of patients. CONCLUSIONS Pudendal angiography with superselective embolization is the treatment of choice. It is well tolerated and ensures a high preservation of premorbid erectile function.

Acute Segmental Testicular Infarction at Contrast-Enhanced Ultrasound: Early Features and Changes During Follow-Up

OBJECTIVE The purpose of this retrospective study was to assess whether contrast-enhanced ultrasound is useful for characterization of acute segmental testicular infarction. MATERIALS AND METHODS Twenty men with acute scrotal pain and suspected segmental testicular infarction underwent contrast-enhanced ultrasound. Three patients underwent orchiectomy. For the other patients, the final diagnosis was based on the absence of tumor markers and a change in the size or shape of the tumor during follow-up. Forty-nine color Doppler ultrasound studies (16 within 24 hours of the onset of pain; 14, 2-17 days after pain onset; 19 after 1 month or more), and 38 contrast-enhanced ultrasound studies (13 within 24 hours after pain onset; nine, 2-17 days; 16 after 1 month or more) were performed. RESULTS Fourteen of 16 lesions examined within 24 hours were oval, and two were wedge shaped. Eight lesions were isoechoic to the testis, six were hypoechoic, and two had mixed echogenicity. Twelve lesions were avascular and four were hypovascular at color Doppler examination. Contrast-enhanced ultrasound showed avascular parenchymal lobules in all cases and without perilesional rim enhancement in 12 of 13 studies. Two to 17 days after the symptoms appeared, contrast-enhanced ultrasound showed avascular lobules in all cases and perilesional rim enhancement in eight examinations. After 1 month or more, contrast-enhanced ultrasound depicted intralesional vascular spots in 12 of 14 infarcts. Perilesional enhancement was absent. CONCLUSION Recognition of lobular morphologic characteristics and the presence of perilesional rim enhancement at contrast-enhanced ultrasound can increase confidence in the diagnosis of segmental testicular infarction compared with reliance on gray-scale and color Doppler findings. Changes in lesion features during follow-up confirm the differential diagnosis from other testicular lesions and allow conservative management.

Follow-up after percutaneous radiofrequency ablation of renal cell carcinoma: contrast-enhanced sonography versus contrast-enhanced CT or MRI.

OBJECTIVE The purpose of this study was to assess, with contrast-enhanced CT or MRI as the reference imaging technique, the diagnostic performance of low-mechanical-index contrast-enhanced sonography in detecting local tumor progression after percutaneous radiofrequency ablation of renal tumors. MATERIALS AND METHODS Twenty-nine patients with 30 renal tumors (18 men, 11 women; mean age, 73 years; range, 53-83 years) underwent percutaneous radiofrequency ablation at a single center between March 1998 and January 2007. The imaging follow-up schedule was both contrast-enhanced sonography and CT or MRI 4 months after completion of treatment and every 4 months for the first year. Thereafter, the follow-up schedule was contrast-enhanced sonography every 4 months with CT or MRI every 8 months. The chi-square test with Yates correction was used to evaluate positive and negative predictive values and accuracy. RESULTS One patient was scheduled to undergo surgical resection, and another patient was lost to follow-up. Twenty-seven patients with 28 renal tumors participated in follow-up. The concordance between contrast-enhanced sonographic and CT or MRI findings was 100% for 27 of 28 tumors (96.4%) that had a hypervascular pattern before treatment. In the case of the tumor that was hypovascular at imaging performed before percutaneous radiofrequency ablation, local tumor progression was missed at contrast-enhanced sonography. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of contrast-enhanced sonography were 96.6%, 100%, 100%, 95.8%, and 98.1%. CONCLUSION Contrast-enhanced sonography is an effective alternative to CT and MRI in the follow-up of renal tumors managed with percutaneous radiofrequency ablation.

Role of contrast enhanced ultrasound in acute scrotal diseases

ObjectiveTo evaluate the efficacy of contrast-enhanced ultrasound (CEUS) in patients with acute scrotal pain not defined at ultrasound (US) with colour Doppler .MethodsCEUS was carried out in 50 patients with acute scrotal pain or scrotal trauma showing testicular lesion of undefined nature at US. The accuracy of US and CEUS findings versus definitive diagnosis (surgery or follow-up) was calculated.ResultsTwenty-three patients had a final diagnosis of testicular tumour, three abscess, eight focal infarction, seven trauma, three testicular torsion, one haematoma. Five patients were negative. Thirty-five patients were operated (23 testicular tumours, six trauma, three testicular torsion, one abscess, one focal infarction, and one haematoma) and 15 underwent medical treatment or were discharged. US provided a definitive diagnosis in 34/50 as compared to the 48/50 patients diagnosed at CEUS. Sensitivity and specificity were 76% and 45% for US and 96% and 100% for CEUS respectively.ConclusionsCEUS was more accurate in the final diagnosis compared to US, potentially reducing the need for further imaging. In particular CEUS can be proposed in emergency in cases where US diagnosis remains inconclusive, namely in infarction, and trauma, when testicular torsion cannot be ruled out, and in identifying testicular mass.

Value of contrast-enhanced ultrasonography for detecting renal infarcts proven by contrast enhanced CT. A feasibility study

The effectiveness of contrast-enhanced ultrasonography (CEUS) in the evaluation of patients with acute renal infarcts was investigated, using contrast-enhanced helical computed tomography (CT) as the reference imaging procedure. Twenty-seven consecutive patients with acute renal infarcts detected with contrast-enhanced helical CT underwent CEUS. Digital cine-clips of CEUS were evaluated by two independent readers blinded to CT findings. Image quality was rated subjectively on a four-point scale. Then, readers were asked to assign a confidence level in diagnosis of renal infarct at the upper pole, medium portion, and lower pole of each kidney according to a five-degree scale, ranging from definitely absent to definitely present. ROC curve analysis was employed to assess the overall confidence of diagnosis of infarct, and weighted kappa values were calculated to assess inter-reader agreement. The subjective image quality of CEUS was lower than the image quality of CT at the upper poles. However, the diagnostic performance of CEUS was excellent (area under receiver-operator characteristic curve 0.992 ± 0.006 for reader 1; 0.991 ± 0.007 for reader 2), with very good inter-reader agreement (weighted kappa value = 0.83). CEUS is a reproducible tool to detect acute renal infarcts in men, with a diagnostic performance approaching that of CT.

Blood Flow Changes in Hepatocellular Carcinoma After the Administration of Thalidomide Assessed by Reperfusion Kinetics During Microbubble Infusion: Preliminary Results

Objectives:We sought to investigate whether thalidomide is able to produce tumor vascular changes in patients with untreatable hepatocellular carcinoma (HCC) that can be detected using microbubble contrast agents. Materials and Methods:Eleven consecutive patients with untreatable HCC underwent contrast-enhanced ultrasound before and during thalidomide administration. Real-time destruction reperfusion kinetics was obtained from a representative HCC nodule and from the surrounding liver parenchyma during SonoVue infusion (Bracco, Milan, Italy) at a constant rate of 0.10 mL/s by using a syringe pump and modelized according to the mathematical function SI = A(1 − exp(−βt)) where the plateau signal intensity A reflects the percent blood volume, the time constant β reflects the average speed of blood, and their product A*β reflects the nutrient blood flow. Results:Size of the representative nodule reduced significantly 3 to 6 months after the start of thalidomide treatment. Before thalidomide administration A, β, and A*β of the index lesion were 44 ± 60 LIU, 0.31 ± 0.40 seconds−1 and 8.1 ± 11.8 LIU/s, respectively). A and A*β reduced significantly after 15 days (26 ± 50 LIU and 2.9 ± 4.8 LIU/s, P < 0.01), 3 months (12 ± 18 LIU, and 4.3 ± 7.7 LIU/s, P < 0.01), and 6 months (13 ± 23 LIU and 2.4 ± 3.7 LIU/s, P < 0.05) of treatment. No statistically significant changes of the exponential time constant β were observed, nor changes of A, β and A*β in the liver parenchyma. Conclusions:Contrast-enhanced ultrasound can be used effectively to evaluate changes in perfusion parameters of HCC nodules during thalidomide administration.