Paola Tombesi

Accuracy of transthoracic sonography in detection of pneumothorax after sonographically guided lung biopsy: prospective comparison with chest radiography.

OBJECTIVE The purpose of this study was to prospectively evaluate the accuracy of transthoracic sonography in the detection of pneumothorax after transthoracic sonographically guided lung biopsy. SUBJECTS AND METHODS Transthoracic sonography was performed on 285 patients after transthoracic sonographically guided lung biopsy. Disappearance of the sliding lung and comettail artifacts and appearance of reverberation artifacts were considered evidence of pneumothorax. Upright chest radiography was performed within 30 minutes of transthoracic sonography. If a discrepancy between transthoracic sonographic and chest radiographic findings occurred, CT was performed. When it was diagnosed, pneumothorax was sonographically monitored. After visualization of resolution of pneumothorax, chest radiography was performed to confirm the resolution. RESULTS Pneumothorax occurred in eight (2.8%) of the patients. Transthoracic sonography depicted all cases of pneumothorax and excluded pneumothorax in the other cases. Chest radiography did not depict one case of pneumothorax, which was confirmed on CT. Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were all 100% for transthoracic sonography and 87.5%, 100%, 100%, 99.6%, and 99.6%, respectively, for chest radiography. The 95% confidence intervals (CI) of the differences in sensitivity, negative predictive value, and overall accuracy were -10% to 35%, -0.1 to 0.9%, and -0.1 to 0.9%. Transthoracic sonographic visualization of resolution of pneumothorax was always confirmed with chest radiography. CONCLUSION These preliminary results suggest that transthoracic sonography is as effective as chest radiography in the detection of pneumothorax after transthoracic sonographically guided lung biopsy and may become the method of choice for excluding, diagnosing, and monitoring pneumothorax after transthoracic sonographically guided biopsy. Chest radiography may be needed only for assessment of the extent of pulmonary collapse after transthoracic sonographic diagnosis of pneumothorax or in the presence of discrepancy between transthoracic sonographic findings and clinical presentation.

Prospective Randomized Trial of Intrapleural Bleomycin Versus Interferon Alfa-2b via Ultrasound-Guided Small-Bore Chest Tube in the Palliative Treatment of Malignant Pleural Effusions

PURPOSE To compare bleomycin pleurodesis and immunotherapy with intrapleural interferon alfa-2b (IFN) in the palliation of malignant pleural effusions. PATIENTS AND METHODS One hundred sixty patients with rapidly recurrent malignant pleural effusion were randomly assigned to intrapleural bleomycin (83 patients) or IFN (77 patients). A 9-French intrapleural catheter was placed under sonographic guidance, and pleural effusion was completely drained before starting the treatment. Bleomycin 0.75 mg/kg was administered as a single dose. An additional dose was given if daily fluid output did not drop to less than 100 mL/d within 3 days. IFN 1 million units/10 kg was administered for six courses at 4-day intervals. Thirty-day and long-term responses were evaluated under the intention-to-treat principle. RESULTS Thirty-day response was 84.3% in the bleomycin arm and 62.3% in IFN arm (P =.002). Median time to progression was 93 days (range, 12 to 395 days) in bleomycin group, and 59 days (range, 7 to 292 days) in the IFN group (P <.001). Median survival was 96 days (range, 15 to 395) and 85 days (range, 16 to 292) in the bleomycin and IFN groups, respectively. Twenty-three patients received two doses of bleomycin, as their daily fluid output remained higher than 100 mL after the first dose. Thirteen of them had complete response, which lasted until death. CONCLUSION Intrapleural bleomycin is more effective than IFN and is a valid option for the palliative treatment of massive, rapidly recurrent malignant pleural effusions. The administration of a second dose of bleomycin to patients not responding to the first one can remarkably improve the overall outcome of the treatment.

Subcapsular Liver Tumors Treated with Percutaneous Radiofrequency Ablation: A Prospective Comparison with Nonsubcapsular Liver Tumors for Safety and Effectiveness

PURPOSE To assess the safety and effectiveness of percutaneous radiofrequency (RF) ablation of subcapsular liver tumors. MATERIALS AND METHODS The study protocol was approved by the institutional review board, and all patients gave written informed consent. One hundred eighty-one patients (79 men, 102 women; age range, 36-85 years) underwent ultrasonographically (US) guided percutaneous RF ablation of 361 primary or secondary (metastatic) liver tumors. Forty-four patients had one or more subcapsular nodules (group 1), and 137 had nonsubcapsular nodules only (group 2). Overall, 80 nodules were subcapsular and 281 were nonsubcapsular. The completeness of the ablation was assessed with contrast material-enhanced computed tomography (CT) 1 month after RF ablation. If residual tumor was documented, RF ablation was repeated. All patients in whom the ablation was complete after the first or second ablation session were monitored with CT or contrast-enhanced US every 3 months. Major complication, complete ablation, and local tumor progression rates were compared by using the chi(2) test or Fisher exact test. RESULTS Three (7%) major complications (intraperitoneal bleeding, skin burn, and tumor seeding) occurred in group 1, and two (1.5%) cases of tumor seeding occurred in group 2 (P = .093). No RF ablation-related deaths occurred. The complete ablation rate was 98% (43 of 44 patients) in group 1 and 98.5% (135 of 137 patients) in group 2 (P = .756). The local tumor progression rate after a median follow-up of 25 months (range, 13-54 months) was 16% (seven of 43 patients) in group 1 and 9.6% (13 of 135 patients) in group 2 (P = .355). CONCLUSION The difference in major complication rate between the subcapsular and nonsubcapsular liver tumors was not significant. The safety of RF ablation of subcapsular tumors seems acceptable, and the effectiveness is comparable to that of RF ablation of nonsubcapsular tumors.

Emerging roles for transthoracic ultrasonography in pulmonary diseases

As a result of many advantages such as the absence of radiation exposure, non-invasiveness, low cost, safety, and ready availability, transthoracic ultrasonography (TUS) represents an emerging and useful technique in the management of pleural and pulmonary diseases. In this second part of a comprehensive review that deals with the role of TUS in pleuropulmonary pathology, the normal findings, sonographic artifacts and morphology of the most important and frequent pulmonary diseases are described. In particular, the usefulness of TUS in diagnosing or raising suspicion of pneumonia, pulmonary embolism, atelectasis, diffuse parenchymal diseases, adult and newborn respiratory distress syndrome, lung cancer and lung metastases are discussed, as well as its role in guidance for diagnostic and therapeutic interventional procedures. Moreover, the preliminary data about the role of contrast enhanced ultrasonography in the study of pulmonary pleural-based lesions are also reported. Finally, the limits of TUS when compared with chest computed tomography are described, highlighting the inability of TUS to depict lesions that are not in contact with the pleura or are located under bony structures, poor visualization of the mediastinum, and the need for very experienced examiners to obtain reliable results.

The second step of the analgesic ladder and oral tramadol in the treatment of mild to moderate cancer pain: A systematic review

Background: To analyse the evidence supporting the widespread use of modified analgesic ladders or oral tramadol as alternatives to codeine/paracetamol for mild to moderate cancer pain. Methods: A systematic review of the literature was independently performed by two authors. The level of evidence and risk/benefit ratio were assessed in all the selected trials. A comprehensive analysis of the level of evidence, risk/benefit ratio and strength of the recommendations was carried out. The analysis was performed using the GRADE system. Results: Eighteen papers were included into the analysis. The level of evidence was low or very low for all the trials, and as a result the risk/benefit ratio was uncertain. Likewise, the strength of the final recommendations was considered weak negative for either the use of modified analgesic ladders (by-passing the second step of the World Health Organization (WHO) analgesic ladder) or the use of oral tramadol as an alternative to codeine/paracetamol in the second step of the WHO analgesic ladder. Conclusions: Data supporting the role of modified two-step analgesic ladders or oral tramadol as an alternative to codeine/paracetamol are insufficient to recommend their routine use in cancer patients with mild to moderate cancer pain.

Emerging roles for transthoracic ultrasonography in pleuropulmonary pathology

As a result of many advantages, such as absence of radiation exposure, non-invasiveness, low cost, safety, and ready availability, transthoracic ultrasonography (TUS) represents an emerging and useful technique in the management of pleural and pulmonary diseases. In this first part of a comprehensive review dealing with the role of TUS in pleuropulmonary pathology, the examination technique, limits, normal findings, and sonographic artefacts and morphology of the most important and frequent pleural diseases are described. In particular, this first part deals with the capability of TUS in detecting pleural effusion and differentiating pleural fluid from pleural thickening; its usefulness in detecting pneumothorax on the basis of the changes in the artefacts detectable in the normally aerated lung and the appearance of pathologic artefacts; and its role in detecting pleural-based lesions and classifying them into extrapleural, pleural, and parenchymal lesions. Finally, the limits of TUS when compared with computed tomography of the chest are described, highlighting the inability of TUS to depict lesions that are not in contact with the pleura or are located under bony structures, poor visualization of the mediastinum, and the need for very experienced examiners to obtain reliable results.

Resection vs thermal ablation of small hepatocellular carcinoma: What's the first choice?

Nowadays, hepatocellular carcinoma (HCC) is frequently diagnosed at an early stage, opening good perspectives to radical treatment by means of liver transplantation, surgical resection, or percutaneous ablation. Liver transplantation is considered the best option, but the lack of liver donors represents a major limitation. Therefore, surgical resection, offering a 5-year-survival rate of over 50%, is considered the first-choice treatment for patients with early stage HCC, whereas percutaneous ablation is usually reserved to patients who are not candidate to surgery. However, in the recent years some trials showed that percutaneous radiofrequency ablation (RFA) can be as effective as surgical resection in terms of overall survival and recurrence-free survival rates in patients with small HCC, and a retrospective comparative study reported 1-, 3-, and 5-year overall survival rates and recurrence-free survival rates significantly better in patients with central HCC measuring 2 cm or smaller treated with RFA than in those treated with surgical resection. RFA is less expensive, less invasive, with lower complication rate and shorter hospital stay than surgical resection, and on the basis of the results of these studies it should be considered the first option in the treatment of very early HCC. However, RFA is size-dependent, so at present the need to achieve an adequate safety margin around the tumor limits to about 2 cm the diameter of the nodules that can be ablated with long-term outcomes comparable to or better than surgical resection. The main goal of the next technical developments of the thermal ablation systems should be the achievement of larger ablation areas with a single needle insertion. In this regard, the recent improvements in microwave energy delivery systems seem to open interesting perspectives to percutaneous microwave ablation, which could become the ablation technique of choice in the next future.

Sonographically Guided Small-Bore Chest Tubes and Sonographic Monitoring for Rapid Sclerotherapy of Recurrent Malignant Pleural Effusions

Objective. To evaluate the role of sonographically guided small‐bore chest catheters and sonographically based monitoring of fluid evacuation in rapid sclerotherapy of malignant pleural effusions. Methods. In 50 patients with recurrent malignant pleural effusions, a 9F catheter was inserted into the pleural space under sonographic guidance. When sonography documented complete fluid evacuation, bleomycin (0.75 mg/kg) was injected via the tube. Fluid drainage was monitored for 12 hours; if fluid output was less than 100 mL, the pleural catheter was removed; otherwise, a second dose of bleomycin was administered after 24 hours. If loculations or fluid reaccumulations due to tube malfunctioning were detected, they were evacuated by sonographically guided thoracentesis, and bleomycin (1.5 mg/100 mL of fluid) was injected through the thoracentesis needle. All patients were monitored for fluid recurrence with thoracic sonography. Results. Twenty‐nine patients received 1 dose of bleomycin, and 21 received 2 doses. In 11 patients with residual loculations, sonographically guided thoracentesis was performed, and bleomycin was injected into the loculations. In 29 patients, pleurodesis was completed within 24 hours; in 21, it was completed within 48 hours. The 30‐day response was 84%; the long‐term response was 60%. No complications or serious side effects were observed. Conclusions. Rapid pleurodesis can be accomplished within 24 to 48 hours, with good short‐ and long‐term responses. Thoracic sonography plays a pivotal role. It guides placement of the pleural catheter and is valuable in the monitoring of fluid evacuation for determining the right time for sclerosing agent administration and in the detection and treatment of loculations or residual pleural fluid due to tube malfunctioning.

Contrast-enhanced ultrasonography in peripheral lung consolidations: What’s its actual role?

AIM To evaluate the diagnostic accuracy of contrast-enhanced ultrasonography (CEUS) in the differential diagnosis between neoplastic and non-neoplastic peripheral pleuro-pulmonary lesions. METHODS One hundred patients with pleural or peripheral pulmonary lesions underwent thoracic CEUS. An 8 microliters/mL solution of sulfur hexafluoride microbubbles stabilized by a phospholipid shell (SonoVue(®)) was used as US contrast agent. The clips were stored and independently reviewed by two readers, who recorded the following parameters: presence/absence of arterial enhancement, time to enhancement (TE), extent of enhancement (EE), pattern of enhancement (PE), presence/absence of wash-out, time to wash-out, and extent of wash-out. After the final diagnosis (based on histopathologic findings or follow-up of at least 15 mo) was reached, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), negative likelihood ratio (NLR) of each CEUS parameter in the differential diagnosis between neoplastic and non-neoplastic lesions were calculated. Furthermore, an arbitrary score based on the ratio between the PPVs of each CEUS parameter was calculated, to evaluate if some relationship could exist between overall CEUS behaviour and neoplastic or non-neoplastic nature of the lesions. RESULTS Five patients were lost at follow-up before a conclusive diagnosis was reached, 53 lesions resulted neoplastic and 42 non-neoplastic. Enhancement in the arterial phase was observed in 53/53 neoplastic lesions and 30/42 non-neoplastic lesions. On the whole, 40/42 non-neoplastic lesions showed absence of enhancement or early enhancement (95.2%) vs 3/53 neoplastic lesions (5.7%). EE was marked in 29/53 (54.7%) neoplastic lesions and 25/30 (83.3%) non-neoplastic lesions, moderate in 24/53 (45.5%) and 5/30 (16.7%), respectively. PE was homogeneous in 6/53 (11.3%) neoplastic lesions and 18/30 (60%) non-neoplastic lesions, inhomogeneous in 47/53 (88.7%) and 12/30 (40%), respectively. 19/30 (63.3%) non-neoplastic lesions enhancing in the arterial phase had no wash-out in the venous phase, 11/30 (36.7%) had late and mild wash-out. Wash-out was early in 26/53 (49%) neoplastic lesions, late in 26/53 (49%), absent in 1 (2%); marked in 16/53 (30.2%), and moderate in 36/53 (67.9%). The delayed enhancement in the arterial phase showed a sensitivity of 94.32%, specificity of 95.2%, PPV of 96.2%, NPV of 93%, PLR of 19.81, and NLR of 0.06 in identifying the neoplastic lesions. All other parameters individually considered showed unsatisfactory values of sensitivity, or specificity, or both, in differentiating neoplastic from non-neoplastic lesions. The median of the overall arbitrary score was 3 (range 0-14) in non-neoplastic lesions, and 16.5 (range 7.0-17.5) in neoplastic lesions (P < 0.001). The correlation between the diagnosis of neoplastic vs non-neoplastic lesion and the score value was statistically significant (r = 0.858, P < 0.001). Based on the score distribution, a cut-off of 7.5 enabled to reach a sensitivity of 98.1%, specificity of 95.1%, PPV 96.3%, NPV 97.5%, PVR 20.1 and NVR 0.02 in differentiating neoplastic from non-neoplastic lesions. CONCLUSION CEUS could be useful in the diagnostic workup of pleuropulmonary lesions. A delayed TE or a score ≥ 7.5 suggest the neoplastic nature of a lesion.

Contrast-Enhanced Sonography as Guidance for Transthoracic Biopsy of a Peripheral Lung Lesion With Large Necrotic Areas

n recent years, sonography has gained increasing appreciation as a useful tool for various diseases of the chest and in particular as reliable and safe guidance for transthoracic biopsy of peripheral lung masses.1 When the lesions are in contact with pleura, sonographically guided percutaneous biopsy is as effective as computed tomographically guided biopsy and offers a number of advantages, such as real-time monitoring of the tip of the needle throughout the procedure and the ability of being performed in bedridden patients.2,3 The recent introduction of real-time, low-mechanical-index, contrast-specific sonographic techniques, producing images based on nonlinear acoustic effects of the interaction of ultrasound with microbubble contrast agents, has greatly increased the diagnostic performance of conventional sonography in liver imaging. These techniques enable characterization of several focal liver lesions and detection of lesions that are not depicted on conventional sonography.4–6 Moreover, the ability of these techniques to show microcirculation allows imaging of perfused tissues, enabling differentiation of viable from necrotic portions of hepatocellular carcinoma lesions.4,7 Although most studies about these new contrast-specific techniques have been focused on the liver, promising results have also been reported in other areas, such as the kidney and breast.4 We report a case in which contrast-enhanced sonography played a key role as guidance for successful percutaneous biopsy of a peripheral lung lesion after conventional sonographically guided biopsy failed in yielding adequate and diagnostic sampling.