R. De Robertis

Diagnostic Performance of Contrast-Enhanced Ultrasound (CEUS) and Contrast-Enhanced Endoscopic Ultrasound (ECEUS) for the Differentiation of Pancreatic Lesions: A Systematic Review and Meta-Analysis

PURPOSE To evaluate CEUS for the diagnosis of pancreatic diseases and its application in the clinical routine with a focus on the value of CEUS in ductal pancreatic carcinoma and its use for the differentiation of neoplastic and non-neoplastic lesions. MATERIALS AND METHODS All prospective and retrospective studies published in any language by March 6, 2014 were included based on the following criteria: use of contrast-enhanced ultrasound (CEUS) and contrast-enhanced endoscopic ultrasound (ECEUS) as the imaging methods, use of histology as the reference method and availability of a complete translation. Two authors analyzed the titles and abstracts of the search results to identify all relevant publications. Two independent readers then analyzed the full articles to identify those meeting the inclusion criteria. Details regarding study design, patient characteristics, interventions, and results were then independently extracted by two radiologists and one reviewer with methodological expertise. Sensitivity, specificity and diagnostic odds ratio (DOR) were used to obtain overall estimates. RESULTS 1293 articles were initially identified. 27 studies met the inclusion criteria. CEUS was the index test in 23 studies while ECEUS was the index test in 4 studies. The primary study objective was met by 20 studies with respect to ductal adenocarcinoma. CEUS sensitivity was evaluated in all studies. The pooled estimate of CEUS sensitivity for the diagnosis of ductal adenocarcinoma was 0.89 (95 % CI, 0.85 - 0.92). 15 out of 20 studies examined CEUS specificity. The average specificity was 0.84 (95 % CI, 0.77 - 0.89). The pooled estimate for DOR was 61.12 (95 % CI, 34.81 - 107.32). With regard to the secondary study objective, the pooled sensitivity and specificity were 0.95 (95 % CI, 0.93 - 0.96) from 14 studies and 0.72 (95 % CI, 0.58 - 0.83) from 13 studies, respectively. The pooled DOR was 57.63 (95 % CI, 33.62 - 98.78). CONCLUSION The sensitivity, specificity, and DOR results show the high value of CEUS for the characterization and differentiation of ductal adenocarinomas from other pancreatic diseases and for cystic pancreatic lesions. For this reason and due to their noninvasive nature, CEUS and ECEUS should be used as the first methods for characterizing neoplastic pancreatic lesions, especially since these are often incidental findings. The methods improve the quality of ultrasound diagnostics and result in faster diagnosis and better disease management.

Contrast-enhanced ultrasonography (CEUS) immediately after percutaneous ablation of hepatocellular carcinoma.

PurposeThis study evaluated the effectiveness of contrast-enhanced ultrasound (CEUS), performed immediately after percutaneous ethanol injection (PEI) or radiofrequency thermal ablation (RFTA), by comparing results with the computed tomography (CT) follow-up.Materials and methodsSixty-nine consecutive patients with a diagnosis of hepatocellular carcinoma (HCC) were included in this prospective study. All patients underwent PEI or RFTA. After treatment, three CEUS enhancement patterns were observed: isovascular, hypovascular and avascular, which were compared with the CT findings. Sensitivity of the avascular pattern at CEUS and effectiveness of the ablative procedures were evaluated and compared with the chi-square test.ResultsNinety hypervascular HCCs, with a mean diameter of 2.6 cm (0.5–4.9 cm), underwent PEI (n=54) and RFTA (n=36). In the first group, CT identified complete necrosis in 28/54 (52%) lesions, 21 (75%) of which had avascular, one (4%) isovascular and six (21%) hypovascular patterns at CEUS. In the second group, CT showed complete necrosis in 31/36 (86%) lesions, all (100%) of which had a corresponding avascular pattern at CEUS. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of the avascular pattern at CEUS compared with CT findings were 75%, 69%, 72%, 72% and 72% for PEI and 100%, 20%, 89%, 100% and 89%, for RFTA, respectively. A statistically significant difference (p<0.05) between the sensitivity of CEUS after PEI and after RFTA and between the necrosis obtained by RFTA and PEI were observed.ConclusionsCEUS performed immediately after percutaneous ablation of hepatocellular carcinoma to evaluate treatment efficacy is compulsory in the case of RFTA but not for PEI.RiassuntoObiettiviStimare l’efficacia dell’ecografia con mezzo di contrasto (CEUS) eseguita immediatamente dopo iniezione percutanea di etanolo (PEI) o termoablazione con radiofrequenza (RFTA), confrontando i risultati con la tomografia computerizzata (TC) di follow-up.Materiali e metodiSessantanove pazienti consecutivi con diagnosi di epatocarcinoma (HCC) sono stati studiati prospetticamente. Le lesioni sono state trattate con PEI o RFTA. Sono stati descritti tre pattern di enhancement alla CEUS (1, isovascolare; 2, ipovascolare; 3, avascolare) e quindi confrontati con la TC di follow-up. La sensibilitá nel riconoscimento del pattern CEUS avascolare dopo PEI e RFTA e l’efficacia delle procedure ablative sono state valutate e confrontate tra loro con il test del gC2.RisultatiNovanta HCC ipervascolari, con diametro medio di 2,6 cm (0,5–4,9 cm), sono stati sottoposti a PEI (54) e RFTA (36). Nel primo gruppo, la TC ha evidenziato necrosi completa in 28/54 (52%) lesioni, di cui 21 (75%) con pattern CEUS avascolare, 1 (4%) isovascolare e 6 (21%) ipovascolare. Nel secondo gruppo, la TC ha mostrato necrosi completa in 31/36 (86%) lesioni, tutte (100%) con pattern CEUS avascolare. Sensibilità, specificità, valore predittivo positivo e negativo ed accuratezza diagnostica per necrosi completa alla TC del pattern CEUS avascolare sono 75%, 69%, 72%, 72% e 72% dopo PEI, 100%, 20%, 89%, 100% e 89% dopo RFTA. La differenza tra la sensibilita della CEUS dopo PEI o RFTA e la differenza tra l’efficacia dei trattamenti è risultata statisticamente significativa (p<0,05).ConclusioniLa CEUS al termine della procedura ablativa dell’epatocarcinoma ai fini della valutazione del successo terapeutico è mandatoria dopo RFTA, ma non dopo PEI.

Comparison between CT and CEUS in the diagnosis of pancreatic adenocarcinoma

PURPOSE The aim of this study is to compare CEUS and MDCT features of pancreatic ductal adenocarcinoma in relation to tumor size. MATERIALS AND METHODS All patients with pathological diagnosis of pancreatic adenocarcinoma and studied by means of CEUS and MDCT were enrolled in this study. Two radiologists evaluated tumor size, site and imaging appearance. Patients in which at least one method yielded a positive result were divided into 4 groups on the basis of lesion size. For each dimensional category, sensitivity of the two imaging methods was calculated and compared using McNemar test. RESULTS One hundred thirty-three patients were included in this study. In 9 of 133 patients neither MDCT nor US/CEUS could identify the lesion, while in 9 of 133 patients only MDCT and in 13 of 133 only US/CEUS could identify the lesion. In the remaining 102 patients, both MDCT and US/CEUS yielded a positive result. US/CEUS sensitivity was 86.47% while MDCT sensitivity was 83.58%, with no statistically significant difference (p = 0.523). For lesions smaller than 2 cm US/CEUS had a 100% sensitivity, while MDCT had a 73.33% sensitivity with no statistically significant difference (p = 0.125). For lesions between 2.1 and 3 cm US/CEUS had a sensitivity of 95.35%, while MDCT had a sensitivity of 83.72% with no statistically significant difference (p = 0.180). For lesions between 3.1 and 4 cm, US/CEUS had a sensitivity of 87.88%, while MDCT had a sensitivity of 93.94% with no statistically significant difference (p = 0.688). For lesions larger than 4 cm US/CEUS, had a sensitivity of 90.91%, while MDCT had a sensitivity of 100% with no statistically significant difference (p = 0.250). CONCLUSION US/CEUS sensitivity in diagnosing pancreatic ductal adenocarcinoma is adequate and does not statistically differ from that of MDCT. US/CEUS sensitivity seems to be higher for small and medium lesions, while MDCT sensitivity is higher for large lesions. By combining both the imaging methods a higher accuracy in diagnosing pancreatic ductal adenocarcinoma can be expected.

Malignant focal liver lesions at contrast-enhanced ultrasonography and magnetic resonance with hepatospecific contrast agent

The aim of this study was to compare the diagnostic accuracy of the late phase of CEUS and the hepatobiliary phase of CE-MR with Gd-BOPTA in the characterization of focal liver lesions in terms of benignity and malignancy. A total of 147 solid focal liver lesions (38 focal nodular hyperplasias, 1 area of focal steatosis, 3 regenerative nodules, 8 adenomas, 11 cholangiocarcinomas, 36 hepatocellular carcinomas and 49 metastases) were retrospectively evaluated in a multicentre study, both with CEUS, using sulphur hexafluoride microbubbles (SonoVue, Bracco, Milan, Italy) and CE-MR, performed with Gd-BOPTA (Multihance, Bracco, Milan, Italy). All lesions thought to be malignant were cytohistologically proven, while all lesions thought to be benign were followed up. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and accuracy were calculated for the late phase of CEUS and the hepatobiliary phase of CE-MRI, respectively, and in combination. Analysis of data revealed 42 benign and 105 malignant focal liver lesions. We postulated that all hypoechoic/hypointense lesions on the two phases were malignant. The diagnostic errors were 13/147 (8.8%) by CEUS and 12/147 (8.2%) by CE-MR. Sensitivity, specificity, PPV, NPV and accuracy of the late phase of CEUS were 90%, 93%, 97%, 80% and 91%, 93%, 97%, 81% and 92% for the hepatobiliary phase of CE-MRI, respectively. If we considered both techniques, the misdiagnosis diminished to 3/147 (2%) and sensitivity, specificity, PPV, NPV and accuracy were 98%, 98%, 99%, 95% and 98%. The combination of the late phase of CEUS and the hepatobiliary phase of CE-MR in the characterization of solid focal liver lesions in terms of benignity and malignancy is more accurate than the two techniques used separately.

CT texture analysis of downstaged ductal adenocarcinoma after chemoteraphy in predicting treatment response

Purpose: To gather opinions of radiographers regarding the use of humour among students and professionals, and to apprehend possible positive and/or negative impacts of its use on the care relationship. Methods: Sample. Six hundred forty-one senior radiographers and 411 first, second or third year undergraduate radiographers, for a total sample of 1052 subjects from all over France. Material. Within a quantitative phase, both professionals radiographers and radiographers-in-training were assessed on several Likert-type scales involving concepts such as the functions of humour, and a second, qualitative phase based on open survey questions further focused on investigating the most salient concepts, notably within the senior radiographer sample. Results: Although radiographer apprentices saw the major benefits of humour in their relationships with patients (i.e. building a trust relationship, distraction technique), the senior radiographers put forward benefits especially regarding their colleagues or their own person (pleasant working environment, coping strategy during stressful events). Positive aspects of humour do prevail over the negative ones in both radiographer groups, but professionals emphasize the contextualized aspects of humour and warn that it may infringe on patients and their dignity. Conclusion: Considering humour as a personal and a professional value among the samples studied opens new perspectives on use of humour and its training within both institutional and educational contexts, preventing any possible harmful use.

3D CT texture analysis of neuroendocrine pancreatic neoplasms

Purpose: To gather opinions of radiographers regarding the use of humour among students and professionals, and to apprehend possible positive and/or negative impacts of its use on the care relationship. Methods: Sample. Six hundred forty-one senior radiographers and 411 first, second or third year undergraduate radiographers, for a total sample of 1052 subjects from all over France. Material. Within a quantitative phase, both professionals radiographers and radiographers-in-training were assessed on several Likert-type scales involving concepts such as the functions of humour, and a second, qualitative phase based on open survey questions further focused on investigating the most salient concepts, notably within the senior radiographer sample. Results: Although radiographer apprentices saw the major benefits of humour in their relationships with patients (i.e. building a trust relationship, distraction technique), the senior radiographers put forward benefits especially regarding their colleagues or their own person (pleasant working environment, coping strategy during stressful events). Positive aspects of humour do prevail over the negative ones in both radiographer groups, but professionals emphasize the contextualized aspects of humour and warn that it may infringe on patients and their dignity. Conclusion: Considering humour as a personal and a professional value among the samples studied opens new perspectives on use of humour and its training within both institutional and educational contexts, preventing any possible harmful use.

Perfusion Changes in Liver Metastases (LM) from Pancreatic Neuroendocrine Tumors (PanNETs) during Everolimus (E) Treatment: Update of Perfusion CT (P-CT) Study

Multidisciplinary Team (MDT) in Neuroendocrine Tumor (NET) Management : Results from the First Global NET Patient (pt) Survey - A Collaboration between the International Neuroendocrine Cancer Alliance (INCA) and Novartis PharmaceuticalsRadioembolization with 90Y-Labelled Resin Microspheres in Patients with Liver Metastases from Neuroendocrine TumorsIncremental Benefit of Preoperative Endoscopic Ultrasound for the Detection of Pancreatic Neuroendocrine Tumors : A Meta-AnalysisSmall intestinal neuroendocrine tumors (SI-NETs) originate from serotonin-producing enterochromaffin (EC) cells in the intestinal mucosa. Somatostatin analogs (SSAs) are mainly used to control hormonal secretion and tumor growth. However, the molecular mechanisms leading to the control of SI-NETs are unknown. Although microRNAs (miRNAs) are post transcriptional regulators deeply studied in many cancers, are not well-defined in SI-NETs. We adopted a two-pronged strategy to investigate SSAs and miRNAs: first, to provide novel insights into how SSAs control NET cells, and second, to identify an exclusive SI-NET miRNA expression, and investigate the biological functions of miRNA targets.To accomplish the first aim, we treated CNDT2.5 cells with octreotide for 16 months. Affymetrix microarray was performed to study gene variation of CNDT2.5 cells in the presence or absence of octreotide. The study revealed that octreotide induces six genes, ANXA1, ARHGAP18, EMP1, GDF15, TGFBR2 and TNFSF15.To accomplish the second aim, SI-NET tissue specimens were used to run genome-wide Affymetrix miRNA arrays. The expression of five miRNAs (miR-96, -182, -183, -196a and -200a) was significantly upregulated in laser capture microdissected (LCM) tumor cells versus LCM normal EC cells, whereas the expression of four miRNAs (miR-31, -129-5p, -133a and -215) was significantly downregulated in LCM tumor cells. We also detected nine tissue miRNAs in serum samples, showing that the expression of five miRNAs is significantly increased in SSA treated patients versus untreated patients. Conversely, SSAs do not change miRNA expression of four low expressed miRNAs. Silencing miR-196a expression was used to investigate functional activities in NET cells. This experimental approach showed that four miR-196a target genes, HOXA9, HOXB7, LRP4 and RSPO2, are significantly upregulated in silenced miR-196a NET cells.In conclusion, ANXA1, ARHGAP18, EMP1, GDF15, TGFBR2 and TNFSF15 genes might regulate cell growth and differentiation in NET cells, and play a role in an innovative octreotide signaling pathway. The global SI-NET miRNA profiling revealed that nine selected miRNAs might be involved in tumorigenesis, and play a potential role as novel markers for follow-up. Indeed, silencing miR-196a demonstrated that HOXA9, HOXB7, LRP4 and RSPO2 genes are upregulated at both transcriptional and translational levels.

Ecografia con mezzo di contrasto (CEUS) immediatamente dopo ablazione percutanea dell'epatocarcinoma

PurposeThis study evaluated the effectiveness of contrast-enhanced ultrasound (CEUS), performed immediately after percutaneous ethanol injection (PEI) or radiofrequency thermal ablation (RFTA), by comparing results with the computed tomography (CT) follow-up.Materials and methodsSixty-nine consecutive patients with a diagnosis of hepatocellular carcinoma (HCC) were included in this prospective study. All patients underwent PEI or RFTA. After treatment, three CEUS enhancement patterns were observed: isovascular, hypovascular and avascular, which were compared with the CT findings. Sensitivity of the avascular pattern at CEUS and effectiveness of the ablative procedures were evaluated and compared with the chi-square test.ResultsNinety hypervascular HCCs, with a mean diameter of 2.6 cm (0.5–4.9 cm), underwent PEI (n=54) and RFTA (n=36). In the first group, CT identified complete necrosis in 28/54 (52%) lesions, 21 (75%) of which had avascular, one (4%) isovascular and six (21%) hypovascular patterns at CEUS. In the second group, CT showed complete necrosis in 31/36 (86%) lesions, all (100%) of which had a corresponding avascular pattern at CEUS. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of the avascular pattern at CEUS compared with CT findings were 75%, 69%, 72%, 72% and 72% for PEI and 100%, 20%, 89%, 100% and 89%, for RFTA, respectively. A statistically significant difference (p<0.05) between the sensitivity of CEUS after PEI and after RFTA and between the necrosis obtained by RFTA and PEI were observed.ConclusionsCEUS performed immediately after percutaneous ablation of hepatocellular carcinoma to evaluate treatment efficacy is compulsory in the case of RFTA but not for PEI.RiassuntoObiettiviStimare l’efficacia dell’ecografia con mezzo di contrasto (CEUS) eseguita immediatamente dopo iniezione percutanea di etanolo (PEI) o termoablazione con radiofrequenza (RFTA), confrontando i risultati con la tomografia computerizzata (TC) di follow-up.Materiali e metodiSessantanove pazienti consecutivi con diagnosi di epatocarcinoma (HCC) sono stati studiati prospetticamente. Le lesioni sono state trattate con PEI o RFTA. Sono stati descritti tre pattern di enhancement alla CEUS (1, isovascolare; 2, ipovascolare; 3, avascolare) e quindi confrontati con la TC di follow-up. La sensibilitá nel riconoscimento del pattern CEUS avascolare dopo PEI e RFTA e l’efficacia delle procedure ablative sono state valutate e confrontate tra loro con il test del gC2.RisultatiNovanta HCC ipervascolari, con diametro medio di 2,6 cm (0,5–4,9 cm), sono stati sottoposti a PEI (54) e RFTA (36). Nel primo gruppo, la TC ha evidenziato necrosi completa in 28/54 (52%) lesioni, di cui 21 (75%) con pattern CEUS avascolare, 1 (4%) isovascolare e 6 (21%) ipovascolare. Nel secondo gruppo, la TC ha mostrato necrosi completa in 31/36 (86%) lesioni, tutte (100%) con pattern CEUS avascolare. Sensibilità, specificità, valore predittivo positivo e negativo ed accuratezza diagnostica per necrosi completa alla TC del pattern CEUS avascolare sono 75%, 69%, 72%, 72% e 72% dopo PEI, 100%, 20%, 89%, 100% e 89% dopo RFTA. La differenza tra la sensibilita della CEUS dopo PEI o RFTA e la differenza tra l’efficacia dei trattamenti è risultata statisticamente significativa (p<0,05).ConclusioniLa CEUS al termine della procedura ablativa dell’epatocarcinoma ai fini della valutazione del successo terapeutico è mandatoria dopo RFTA, ma non dopo PEI.

Contrast-enhanced ultrasonography (CEUS) immediately after percutaneous ablation of hepatocellular carcinoma@@@Ecografia con mezzo di contrasto (CEUS) immediatamente dopo ablazione percutanea dell’epatocarcinoma

PurposeThis study evaluated the effectiveness of contrast-enhanced ultrasound (CEUS), performed immediately after percutaneous ethanol injection (PEI) or radiofrequency thermal ablation (RFTA), by comparing results with the computed tomography (CT) follow-up.Materials and methodsSixty-nine consecutive patients with a diagnosis of hepatocellular carcinoma (HCC) were included in this prospective study. All patients underwent PEI or RFTA. After treatment, three CEUS enhancement patterns were observed: isovascular, hypovascular and avascular, which were compared with the CT findings. Sensitivity of the avascular pattern at CEUS and effectiveness of the ablative procedures were evaluated and compared with the chi-square test.ResultsNinety hypervascular HCCs, with a mean diameter of 2.6 cm (0.5–4.9 cm), underwent PEI (n=54) and RFTA (n=36). In the first group, CT identified complete necrosis in 28/54 (52%) lesions, 21 (75%) of which had avascular, one (4%) isovascular and six (21%) hypovascular patterns at CEUS. In the second group, CT showed complete necrosis in 31/36 (86%) lesions, all (100%) of which had a corresponding avascular pattern at CEUS. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of the avascular pattern at CEUS compared with CT findings were 75%, 69%, 72%, 72% and 72% for PEI and 100%, 20%, 89%, 100% and 89%, for RFTA, respectively. A statistically significant difference (p<0.05) between the sensitivity of CEUS after PEI and after RFTA and between the necrosis obtained by RFTA and PEI were observed.ConclusionsCEUS performed immediately after percutaneous ablation of hepatocellular carcinoma to evaluate treatment efficacy is compulsory in the case of RFTA but not for PEI.RiassuntoObiettiviStimare l’efficacia dell’ecografia con mezzo di contrasto (CEUS) eseguita immediatamente dopo iniezione percutanea di etanolo (PEI) o termoablazione con radiofrequenza (RFTA), confrontando i risultati con la tomografia computerizzata (TC) di follow-up.Materiali e metodiSessantanove pazienti consecutivi con diagnosi di epatocarcinoma (HCC) sono stati studiati prospetticamente. Le lesioni sono state trattate con PEI o RFTA. Sono stati descritti tre pattern di enhancement alla CEUS (1, isovascolare; 2, ipovascolare; 3, avascolare) e quindi confrontati con la TC di follow-up. La sensibilitá nel riconoscimento del pattern CEUS avascolare dopo PEI e RFTA e l’efficacia delle procedure ablative sono state valutate e confrontate tra loro con il test del gC2.RisultatiNovanta HCC ipervascolari, con diametro medio di 2,6 cm (0,5–4,9 cm), sono stati sottoposti a PEI (54) e RFTA (36). Nel primo gruppo, la TC ha evidenziato necrosi completa in 28/54 (52%) lesioni, di cui 21 (75%) con pattern CEUS avascolare, 1 (4%) isovascolare e 6 (21%) ipovascolare. Nel secondo gruppo, la TC ha mostrato necrosi completa in 31/36 (86%) lesioni, tutte (100%) con pattern CEUS avascolare. Sensibilità, specificità, valore predittivo positivo e negativo ed accuratezza diagnostica per necrosi completa alla TC del pattern CEUS avascolare sono 75%, 69%, 72%, 72% e 72% dopo PEI, 100%, 20%, 89%, 100% e 89% dopo RFTA. La differenza tra la sensibilita della CEUS dopo PEI o RFTA e la differenza tra l’efficacia dei trattamenti è risultata statisticamente significativa (p<0,05).ConclusioniLa CEUS al termine della procedura ablativa dell’epatocarcinoma ai fini della valutazione del successo terapeutico è mandatoria dopo RFTA, ma non dopo PEI.