Piercarlo Ceccotti

Potential Value of Contrast-Enhanced Intraoperative Ultrasonography During Partial Hepatectomy for Metastases: An Essential Investigation Before Resection?

Objective:The aim of the study was to assess the clinical value of contrast-enhanced intraoperative ultrasound (CE-IOUS) as a novel tool in the hepatic staging of patients undergoing liver resection. Methods:Sixty patients scheduled to undergo liver resection for metastatic disease were studied. Preoperative staging with contrast-enhanced CT and/or MR scans was performed within 2 to 6 weeks of operation. Following exploration, intraoperative ultrasound (IOUS) was performed using an HDI-5000 scanner (Philips) and a finger-probe with pulse inversion harmonic (PIH) capability. CE-IOUS in the PIH mode was performed in a standardized protocol (low MI: 0.02–0.04) after intravenous injection of 3–4 mL of SonoVue (Bracco spa, Milan); all detected lesions on precontrast and postcontrast scans were counted and mapped. Any alteration in surgical management was documented following CE-IOUS compared with IOUS. Results:Three patients were excluded due to disseminated disease on exploration. CE-IOUS was significantly more sensitive than CT/MR and IOUS in detecting liver metastases (96.1% versus 76.7% and 81.5%, respectively) (P < 0.05); it altered surgical management in 29.8% (17 of 57) of cases, due to 1) additional metastases in 19.3% (11 of 57), 2) less metastases in 3.5% (2 of 57), 3) benign lesions wrongly diagnosed as metastasis on IOUS/CT in 5.3% (3 of 57), and 4) vascular proximity in 1.8% (1 of 57). Management was unchanged in 70.2% (40 of 57) despite additional lesions detected in 3.5% (2 of 57) and benign lesion wrongly diagnosed on IOUS and CT as metastasis in 1.8% (1 of 57). CE-IOUS altered combined IOUS/CT/MR staging in 35.1%. Conclusion:These preliminary results suggest CE-IOUS is an essential tool prior to liver resection for metastases.

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.

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 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.

Sonographically Guided Biopsy and Sonographic Monitoring in the Diagnosis and Follow-up of 2 Cases of Sarcoidosis With Hepatic Nodules and Inconclusive Thoracic Findings

Objective. To report 2 cases in which abdominal sonography played a useful role in diagnosing sarcoidosis with early nodular hepatosplenic manifestations. Methods. In the first case, an asymptomatic woman with increased liver enzyme values underwent sonography, which showed multiple hypoechoic nodules in the liver and spleen. Computed tomography confirmed the hepatosplenic findings and showed micronodular infiltrates of both lung fields, without hilar and mediastinal lymph‐adenopathy. In the second case, in a woman with a cough, dyspnea, and increased liver enzyme levels, thoracic computed tomography showed right pleural effusion causing partial atelectasis of the lower and middle lobes and mediastinal lymphadenopathy. Results. Sonography and computed tomography showed multiple nodules of the liver and spleen and retroperitoneal lymphadenopathy. In both cases, bronchoscopy, bronchial and bronchioloalveolar lavages, and transbronchial and mediastinal biopsies had negative results. Sonographically guided biopsy of the hepatic nodules was carried out, and sarcoid granulomas were detected in the portal areas. After 3 months of steroid therapy, liver enzyme values nearly normalized, and sonography showed the disappearance of all abdominal lesions. The first patient underwent control computed tomography, which confirmed the regression of the disease; the second patient refused control computed tomography. Conclusions. Sarcoidosis can occur with atypical onset, and in selected cases sonography may play a useful role in its diagnosis and follow‐up.

Portal Vein Thrombosis May Alter the Correct Evaluation of Hepatocellular Carcinoma With the Sonographic Contrast Pulse Sequence Technique

urrent developments in nonlinear imaging modes, combined with second-generation sonographic contrast agents, enable continuous, real-time imaging of blood flow in normal and pathologic tissues, allowing for the characterization of focal liver lesions similar to that of contrastenhanced computed tomography (CT) and magnetic resonance imaging.1–4 The contrast pulse sequence (CPS) imaging mode is a novel nonlinear imaging technique that is based on the processing of nonlinear signals in the fundamental frequency band, with improved sensitivity to contrast agent depiction. It is particularly useful for characterizing benign lesions, which show progressive enhancement in the arterial and portal venous phases, with contrast uptake/retention in the late phase similar to that of the adjacent liver.1 Conversely, metastases show variable arterial enhancement followed by rapid wash-out in the portal venous phase and appear as filling defects in the late phase. Hepatocellular carcinoma (HCC) is usually characterized by rapid contrast wash-in and wash-out during the arterial and portal phases, respectively, with less retention of contrast than the adjacent parenchyma in the late phase1–4; however, well-differentiated HCC may show considerable contrast uptake in the late phase, making the differentiation difficult between HCC and benign lesions, such as regenerating or dysplastic nodules. In this regard, the accurate diagnosis of HCC by using the CPS mode may be problematic, especially in the presence of altered hepatic perfusion attributable to portal thrombosis. In this report we describe the contrast-enhanced sonographic imaging of HCC in a cirrhotic patient with portal vein thrombosis. Computed tomographic and magnetic resonance images are also provided. Received June 15, 2006, from the Department of Fourth Clinical Surgery, University of Rome “La Sapienza,” Rome, Italy (P.C., M.C.); Department of Radiology, Glasgow Royal Infirmary, Glasgow, Scotland (E.L.); Department of Radiology, School of Medicine, University of Patras, Patras, Greece (C.P.K.); National Institute for the Infectious Diseases “Lazzaro Spallanzani” Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy (U.V.-C.); and Department of Internal Medicine, Section of Interventional Ultrasound, St Anna Hospital, Ferrara, Italy (S.S.). Revision requested July 3, 2006. Revised manuscript accepted for publication July 26, 2006. Address correspondence to Marcello Caratozzolo, MD, Department of Fourth Clinical Surgery, University of Rome “La Sapienza,” Policlinico Umberto I, Viale del Policlinico, 155-00161 Rome, Italy. E-mail: marcello.caratozzolo@uniroma1.it Abbreviations CPS, contrast pulse sequence; CT, computed tomography; HCC, hepatocellular carcinoma; MI, mechanical index