Role of low-mechanical index CEUS in the differentiation between low and high grade bladder carcinoma: a pilot study.

PURPOSE: To assess the efficacy of low-mechanical index contrast-enhanced ultrasonography (CEUS) in the differentiation of a series of histologically proven bladder lesions identified via conventional cystoscopy and biopsied. MATERIALS AND METHODS: 36 patients (mean age: 62 years; range 45 - 72 years) with bladder lesions previously detected by color power Doppler ultrasonography (CDUS) were prospectively examined with low-mechanical index contrast-enhanced US after bolus administration of 2.4 ml of Sonovue (Bracco, Milan, Italy). All lesions were evaluated in real-time continuous scanning for 2 minutes and the videos were registered. Two ultrasound (US) experts evaluated the videos by consensus and assigned a score to the enhancement pattern. Subsequently, a specific sonographic quantification software (Qontrast, Bracco, Milan, Italy) based on pixel by pixel signal intensity over time was used to obtain contrast-enhanced sonographic perfusion maps for each lesion. Time-intensity curves (TICs) of each lesion were then extracted from the region of interest positioned within the lesion and in the closest bladder wall. The sensitivity and specificity of CDUS and CEUS were compared using McNemar's test. All patients subsequently underwent conventional cystoscopy with biopsy or transurethral resection. RESULTS: 22 high-grade and 14 low-grade transitional cell carcinomas (TCCs) were histologically diagnosed (mean diameter 2.1 cm; range: 1 - 4.5 cm). The sensitivity and specificity of CDUS were 86.4% (19 / 22; 95% CI = 66.7 - 95.3%) and 42.9% (6 / 14; 95% CI = 21.4 - 67.4%), respectively. The sensitivity and specificity of CEUS were 90.9% (20 / 22; 95% CI = 72.2 - 97.5%) and 85.7% (12 / 14; 95% CI = 60.1 - 95.9%), respectively. The sensitivity and specificity of CEUS using TICs were 95.4% (21 / 22; 95% CI = 78.2 - 99.2%) and 85.7% (12 / 14; 95% CI = 60.1 - 95.9%), respectively. There was no significant difference between the sensitivity of CDUS versus CEUS, CDUS versus TIC, and CEUS versus TIC (p > 0.05; McNemar's test). The specificity of CEUS and TIC was significantly higher than that of CDUS (p < 0.05; McNemar test). CONCLUSION: CEUS is a reliable noninvasive method for differentiating low- and high-grade bladder carcinomas since it provides typical enhancement patterns as well as specific contrast-sonographic perfusion curves. However, further studies involving larger patient populations is mandatory to confirm these promising results.

Detection of hepatic metastases from colorectal cancer: prospective evaluation of gray scale US versus SonoVue® low mechanical index real time-enhanced US as compared with multidetector-CT or Gd-BOPTA-MRI.

PURPOSE: To compare ultrasound (US), low-mechanical index contrast enhanced US (CEUS) and multidetector-CT (MDCT) for the detection of hepatic metastases from colorectal cancer. METHODS AND MATERIALS: From January to June 2006, 110 patients (65 males, 45 females; mean age 62 years; range 39-78) with suspected hepatic lesions from colorectal cancer were prospectively evaluated with US, CEUS and MDCT by two independent readers. Intraoperative ultrasonography (IOUS, n = 45) or a follow-up up for at least 6 months by using MDCT or Gd-BOPTA-enhanced MRI was considered the gold standard. McNemar test was employed. RESULTS: Reference standards revealed 430 metastases in 110 patients. On a patient-by-patients analysis, CEUS improved US sensitivity from 67.4-71.6% to 93.4-95.8% (p < 0.05). On a lesion-by-lesion analysis, CEUS improved the sensitivity of US from 60.9-64.9% to 85.3-92.8% (p < 0.001). The specificity increased from 50-60% to 76.7-83.3%. No significant differences in sensitivity or specificity between CEUS and MDCT were found. Contrast-enhanced US was significantly more sensitive than baseline US in the detection of metastases smaller than 1 cm (p < 0.001) with an increase in sensitivity from 29.1-35% to 63.3-76.6% no significant statistical difference was identified when compared with MDCT (sensitivity of 73.3-75.8%). CONCLUSIONS: CEUS is significantly more accurate than US and highly comparable with MDCT in the detection of liver metastases from colorectal cancer. Therefore, in the evaluation of patients with suspected hepatic metastases from colorectal tumour, US examination must be performed after contrast administration.

Diagnostic imaging in the study of human hepatobiliary fascioliasis.

PURPOSE: Fascioliasis is a rare zoonotic disease caused by the trematode Fasciola hepatica. We present the typical patterns of hepatobiliary fascioliasis observed in ten patients studied with multimodality imaging. MATERIALS AND METHODS: Between 2002 and 2005, ten women with fascioliasis were admitted to the Brigham and Women's Hospital, Harvard Medical School (BWH), with abdominal pain and mild fever. All imaging modalities, including ultrasound (US), computed tomography (CT), magnetic resonance (MR) imaging (n = 2) and endoscopic retrograde cholangiopancreatography (ERCP) (n = 1) were reviewed by two expert radiologists working in consensus. RESULTS: In all patients (10/10, 100%), US showed parenchymal heterogeneity characterised by multiple subcapsular and peribiliary hypoechoic nodular lesions that were ill-defined and coalesced into tubular or tortuous structures. In six patients (6/10, 60%), the lesions appeared hypoechoic, whereas in four patients (4/10, 40%), there was an alternation of hyperechoic and hypoechoic nodules. On CT, all patients (10/10, 100%) showed hypodense patchy lesions in subcapsular, peribiliary or periportal locations, which coalesced to form tubular structures and were more evident during the portal phase. Lesion diameter ranged from 2 cm to 7 cm. Capsular enhancement was seen in four cases on CT (4/10, 40%) and in one also at MR imaging. MR imaging, performed in two patients, confirmed the presence of the lesions, which appeared hyperintense on T2-weighted images and were characterised by mild peripheral enhancement after gadolinium administration. Four patients had gallbladder wall thickening (4/10, 40%), with parasites in the gallbladder lumen. CONCLUSIONS: Although rare, hepatobiliary fascioliasis should be considered in the differential diagnosis in the appropriate clinical scenario, especially in patients coming from endemic areas. The typical imaging pattern of fascioliasis is the presence of subcapsular, peribiliary or periportal nodules that are usually ill-defined and coalesce, giving rise to a tubular or tortuous appearance.

Is contrast-enhanced US alternative to spiral CT in the assessment of treatment outcome of radiofrequency ablation in hepatocellular carcinoma?

PURPOSE: The present study was conducted to assess the efficacy of contrast-enhanced ultrasound with low mechanical index in evaluating the response of percutaneous radiofrequency ablation treatment of hepatocellular carcinoma by comparing it with 4-row spiral computed tomography. MATERIALS AND METHODS: 100 consecutive patients (65 men and 35 women; age range: 62 - 76 years) with solitary hepatocellular carcinomas (mean lesion diameter: 3.7 cm +/- 1.1 cm SD) underwent internally cooled radiofrequency ablation. Therapeutic response was evaluated at one month after the treatment with triple-phasic contrast-enhanced spiral CT and low-mechanical index contrast-enhanced ultrasound following bolus injection of 2.4 ml of Sonovue (Bracco, Milan). 60 out of 100 patients were followed up for another 3 months. Contrast-enhanced sonographic studies were reviewed by two blinded radiologists in consensus. Sensitivity, specificity, NPV and PPV of contrast-enhanced ultrasound examination were determined. RESULTS: After treatment, contrast-enhanced ultrasound identified persistent signal enhancement in 24 patients (24 %), whereas no intratumoral enhancement was detected in the remaining 76 patients (76 %). Using CT imaging as gold standard, the sensitivity, specificity, NPV, and PPV of contrast enhanced ultrasound were 92.3 % (95 % CI = 75.9 - 97.9 %), 100 % (95 % CI = 95.2 - 100 %), 97.4 % (95 % CI = 91.1 - 99.3 %), and 100 % (95 % CI = 86.2 - 100 %). CONCLUSION: Contrast-enhanced ultrasound with low mechanical index using Sonovue is a feasible tool in evaluating the response of hepatocellular carcinoma to radiofrequency ablation. Accuracy is comparable to 4-row spiral CT.

Devescovinid trichomonad with axostyle-based rotary motor ("Rubberneckia"): taxonomic assignment as Caduceia versatilis sp. nov.

An amitochondriate trichomonad cell of the family Devescovinidae (Class Parabasalia), helped demonstrate the fluid model of lipoprotein cell membranes. This wood-ingesting symbiont in the hindgut of the dry wood-eating termite Cryptotermes cavifrons is informally known to cell biologists as "Rubberneckia". As the microtubular axo-style complex generates force causing clockwise movement of the entire anterior portion of the cell at the shear zone the protist displays "head" rotation. Studies by phase contrast and videomicroscopy of live cells, of whole mounts by scanning, and thin sections by transmission electron microscopy extend the observations of Tamm and Tamm [24-26] and Tamm [19-23]. Habitat, cell shape, size, nuclear features, parabasal apparatus and other morphological details permit the assignment of "Rubberneckia" to Kirby's cosmopolitan genus Caduceia. This large-sized devescovinid has distinctive parabasal gyres, an axostylar rotary, motor, and regularly-associated nonflagellated, fusiform and flagellated rod epibiotic surface bacteria. In addition to regularly aligned epibionts intranuclear and endocytoplasmic bacteria are abundant and hydrogenosomes are Present. "Rubberneckia" is compared here to the other seven species of Caduceia. Since it is clearly sufficiently distinctive to warrant new species status, we named it C. versatilis.

Vascular leiomyoma presenting as medial joint line pain of the knee.

Vascular leiomyoma or angioleiomyoma is a rare benign solitary smooth muscle tumor that occurs mostly in the extremities. Most of these tumors are composed of venous vessels, but in some reports small arteries have been detected in the tumors.We present a rare case of a 60-year-old man with a subcutaneous vascular leiomyoma of the right knee. Clinical findings, ultrasound (US), magnetic resonance (MR), and histopathologic features are reported, and the literature is reviewed. The knowledge of specific imaging findings allows to include vascular leiomyoma in the differential diagnosis of lower extremity subcutaneous masses and to achieve an early accurate diagnosis.

Post-transplant hepatic complications: Imaging findings.

Transplantation is considered definitive therapy for acute or chronic irreversible pathologies of the liver, and the increased survival rates are mainly due to improved immunosuppressive therapies and surgical techniques. However, early diagnosis of possible graft dysfunction is crucial to liver graft survival. Diagnostic imaging plays an important role in the evaluation of the liver before and after transplant and in the detection of complications such as vascular and biliary diseases, acute and chronic rejection and neoplastic recurrence. Integrated imaging using color-Doppler, CT, MRI and traditional x-ray reach a high level of sensitivity and specificity in the management of transplanted patients.

SommarioIl trapianto epatico è il migliore trattamento per l'insufficenza epatica terminale.Il miglioramento della sopravvivenza postoperatoria è dovuta soprattutto al perfezionamento della terapia immunosoppressiva e delle tecniche chirurgiche.L'imaging radiologico riveste un ruolo importante sia per la valutazione preoperatoria dei pazienti, identificando eventuali varianti anatomiche che richiedono una modifica della tecnica chirurgica, sia per la diagnosi e la terapia precoce delle complicanze post trapianto, contribuendo alla riduzione della mortalità e della morbilità.

Is color-Doppler US a reliable method in the follow-up of transjugular intrahepatic portosystemic shunt (TIPS)?

Transjugular intrahepatic portosystemic shunt (TIPS) has become a widely accepted treatment for complications of portal hypertension. Shunt or hepatic vein stenoses or occlusions are common short- and mid-term complications of the procedure, with a one-year primary patency ranging from 25% to 66%. When promptly identified, shunt stenosis or occlusion may be treated before the recurrence of gastrointestinal bleeding or ascites. The revision is usually successful and the primary-assisted patency of TIPS is approximately 85% at one year.Doppler sonography is a widely accepted screening modality for TIPS patients, both as a routine follow-up in asymptomatic patients and in those cases with clinically suspected TIPS malfunction.In a routine US follow-up, a TIPS patient is scheduled for a control 24 h after the procedure, and then after one week, 1 month, 3 months, and at 3-month intervals thereafter. Venography is at present performed solely on the basis of a suspected shunt dysfunction during the sonographic examination.Color-Doppler sonography is the most reliable method for monitoring the shunt function after TIPS implantation. Several studies have shown that Doppler sonography is a sensitive and relatively specific way to detect shunt malfunction, particularly when multiple parameters are examined. Achieving high sensitivity is optimal so that malfunctioning shunts can be identified and shunt revision can be performed before symptomatic deterioration. Venous angiography is at present indicated only on the basis of US suspicion of shunt compromise. Power-Doppler US and US contrast media can be useful in particular conditions, but are not really fundamental.

SommarioLa derivazione portosistemica per via percutanea transgiugulare, nota con l'acronimo TIPS, è diventata una modalità di trattamento delle complicanze dell'ipertensione portale. Stenosi od occlusioni dello shunt o delle vene epatiche sono complicanze a breve e medio termine, con pervietà a un anno compresa tra 25% e 66%. Se la diagnosi di stenosi od occlusione è precoce, il trattamento consente di evitare recidiva di ematemesi o ascite. La revisione dello shunt è generalmente di successo e la pervietà assistita della TIPS è di circa il 5% a un anno.Le tecniche Doppler sono ampiamente accettate nelle procedure di screening dei pazienti con TIPS, sia nel paziente asintomatico sia in quello con sospetto clinico di malfunzione dello shunt. In una procedura di follow-up la valutazione color-Doppler viene eseguita dopo 24 ore, dopo 7 giorni, dopo 1 mese, dopo 3 mesi e quindi ogni 3 mesi. La venografia viene oramai effettuata soltanto su precisa indicazione dell'esame ecografico. Il color-Doppler è la metodica migliore per il monitoraggio del funzionamento dello shunt dopo l'impianto di una TIPS. Molti studi hanno dimostrato che il Doppler è sensibile e relativamente specifico nell'identificare la malfunzione dello shunt, particolarmente se molteplici parametri vengono esaminati contemporaneamente. L'elevata sensibilità consente di identificare gli shunt malfunzionanti indirizzandoli alla revisione prima del peggioramento delle condizioni. La venografia viene effettuata solo su indicazione della valutazione color- e power-Doppler. L'utilizzo del power-Doppler e del mezzo di contrasto può essere utile in particolari condizioni, ma non è realmente fondamentale.