Elevated Native T1 Values in the Remote Myocardium Supplied by Obstructive Non-Infarct Related Coronary Arteries in Post-STEMI Cardiac Magnetic Resonance.

INTRODUCTION: Native T1 mapping values are elevated in acutely injured myocardium. We sought to study whether native T1 values, in the non-infarct related myocardial territories, might differ when supplied by obstructive or nonobstructive coronary arteries. METHODS: Consecutive patients (N = 60, mean age 59 years) with the first STEMI following primary percutaneous coronary intervention, underwent cardiac magnetic resonance within 5 ± 2 days. A retrospective review of coronary angiography reports classified coronary arteries as infarct-related coronary artery (IRA) and non-IRA. Obstructive coronary artery disease (CAD) was defined as stenosis ≥50%. Native T1 values were presented using a 16-segment AHA model according to the three main coronary territories: left anterior descending (LAD), left circumflex (LCX), and right coronary artery (RCA). RESULTS: The cutoff native T1 value for predicting obstructive non-IRA LAD was 1,309 msec with a sensitivity and specificity of 67% and 82%, respectively (AUC 0.76, 95% CI: 0.57-0.95, p = 0.04). The cutoff native T1 value for predicting obstructive non-IRA RCA was 1,302 msec with a sensitivity and specificity of 83% and 55%, respectively (AUC 0.7, 95% CI: 0.52-0.87, p = 0.05). Logistic regression model adjusted for age and infarct size demonstrated that native T1 was an independent predictor for the obstructive non-IRA LAD (OR 4.65; 1.32-26.96, p = 0.05) and RCA (OR 3.70; 1.44-16.35, p = 0.03). CONCLUSION: Elevated native T1 values are independent predictors of obstructive non-IRA in STEMI patients. These results suggest the presence of concomitant remote myocardial impairment in the non-infarct territories with obstructive CAD.

Preoperative evaluation of tumor depth of invasion in oral squamous cell carcinoma with intraoral ultrasonography: a retrospective study.

OBJECTIVE: The aim of this study was to evaluate the efficacy of preoperative intraoral ultrasonography (US) in the assessment of tumor depth of invasion (DOI) in oral squamous cell carcinoma (OSCC). STUDY DESIGN: Records of 32 patients with biopsy-proven OSCC who underwent preoperative intraoral US were retrospectively reviewed. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy as indicated by receiver operating characteristic (ROC) analysis were measured for US in the assessment of the infiltration of the tumor beyond the lamina propria into the submucosa. The correlations between US and histologic DOI, and between US DOI and US diameter of the lesion, were assessed. RESULTS: US sensitivity, specificity, PPV, and NPV in the assessment of the infiltration of the tumor beyond the lamina propria into the submucosa were 93.1%, 100%, 100%, and 60%, respectively. The area under the ROC curve was 0.96. A significant correlation was found between the measurements of US DOI and histological DOI (r = 0.907). A moderate correlation was found between US DOI and US diameter (r = 0.591). CONCLUSIONS: Intraoral US has potential in preoperatively determining tumor DOI and may provide additional guidance for optimal planning of therapy for OSCC patients .

Correlation of body composition by computerized tomography and metabolic parameters with survival of nivolumab-treated lung cancer patients.

PURPOSE: Weight loss is a well-recognized prognostic parameter for survival of lung cancer patients. Computerized-tomography (CT)-based analysis of body composition and blood-based metabolic evaluation are promising prognostic tools. We aimed to assess the correlation between albumin, body mass index (BMI), skeletal muscle mass index (SMI), fat-free mass index (FFMI), fat mass index (FMI) and weight change, as well as their correlation with survival of lung cancer patients on nivolumab treatment. METHODS: Data were retrospectively collected. Weight was measured at a diagnosis of stage 4 disease and before start of nivolumab. Albumin levels were measured before starting nivolumab. BMI, SMI, FFMI, and FMI were evaluated from CT scans performed at start of nivolumab. Overall survival (OS) was from starting of nivolumab to death or censured at last follow-up. Statistical analysis was done to identify correlation between the various factors and between those factors and survival. RESULTS: Forty-six patients with advanced non-small cell lung cancer (NSCLC) were included. Median follow-up was 22 months. Pathology was Adenocarcinoma/Squamous/non-other specified in 25/15/6 respectively. All patients received nivolumab as an advanced-line treatment for stage IV NSCLC. We observed a significant correlation of weight loss (P=0.01, HR=2.85) and albumin (P=0.043, HR=0.34) with OS in multivariate analysis. A significant correlation was found between BMI to SMI, FFMI, FMI, and weight change. CONCLUSION: Weight loss and low albumin levels are significant negative prognostic factors for NSCLC patients on immunotherapy. CT-based parameters of body composition remain to be proven as more reliable than standard clinical parameters.

Mitral Annulus Calcium Score.

BACKGROUND: The risk of conduction system abnormalities (CSA) after transcatheter aortic valve implantation remains high. We aimed to evaluate the impact of mitral annular calcium (MAC) score on the development of CSA after transcatheter aortic valve implantation. METHODS: Consecutive patients (n=168), with severe AoV stenosis, without prior CSA, underwent computed tomography transcatheter AoV implantation followed by device implantation; CoreValve (n=72) and SAPIEN (n=96). MAC, AoV, and left ventricular outflow tract calcium (Ca++) scores were quantitated from noncontrast ECG-gated computed tomography using Agatston method. The primary end point was a combination of complete left bundle branch block or high-degree atrioventricular block. Logistic regression was used to analyze the predictive value of Ca++ scores of different locations. RESULTS: The primary end point was documented in 62% of the fourth quartile MAC score (>2700) patients as compared with 31% of the first quartile (<140); P=0.03. Logistic regression analysis documented MAC score as an independent predictor either of primary end point as a continuous variable (odds ratio: 1.02, 95% [CI]: 1.00 - 1.03, p = 0.021) or as quartile cutoffs, whereas Q4 was a strong and independent predictor (odds ratio: 3.69, 95% [CI]: 1.37 - 9.95, p = 0.010). CONCLUSIONS: MAC score was found to be an independent predictor of CSA in patients undergoing transcatheter aortic valve implantation without preexisting CSA. Therefore, the current study suggests that patients with high MAC score category (fourth MAC score quartile) should be considered at high risk for CSA, warranting closer monitoring. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02023060.

Automated classification of focal breast lesions according to S-detect: validation and role as a clinical and teaching tool.

PURPOSE: To assess the diagnostic performance and the potential as a teaching tool of S-detect in the assessment of focal breast lesions. METHODS: 61 patients (age 21-84 years) with benign breast lesions in follow-up or candidate to pathological sampling or with suspicious lesions candidate to biopsy were enrolled. The study was based on a prospective and on a retrospective phase. In the prospective phase, after completion of baseline US by an experienced breast radiologist and S-detect assessment, 5 operators with different experience and dedication to breast radiology performed elastographic exams. In the retrospective phase, the 5 operators performed a retrospective assessment and categorized lesions with BI-RADS 2013 lexicon. Integration of S-detect to in-training operators evaluations was performed by giving priority to S-detect analysis in case of disagreement. 2 × 2 contingency tables and ROC analysis were used to assess the diagnostic performances; inter-rater agreement was measured with Cohen's k; Bonferroni's test was used to compare performances. A significance threshold of p = 0.05 was adopted. RESULTS: All operators showed sensitivity > 90% and varying specificity (50-75%); S-detect showed sensitivity > 90 and 70.8% specificity, with inter-rater agreement ranging from moderate to good. Lower specificities were improved by the addition of S-detect. The addition of elastography did not lead to any improvement of the diagnostic performance. CONCLUSIONS: S-detect is a feasible tool for the characterization of breast lesions; it has a potential as a teaching tool for the less experienced operators.

Strain ratio ultrasound elastography increases the accuracy of colour-Doppler ultrasound in the evaluation of Thy-3 nodules. A bi-centre university experience.

OBJECTIVES: To assess whether ultrasound elastography (USE) with strain ratio increases diagnostic accuracy of Doppler ultrasound in further characterisation of cytologically Thy3 thyroid nodules. METHODS: In two different university diagnostic centres, 315 patients with indeterminate cytology (Thy3) in thyroid nodules aspirates were prospectively evaluated with Doppler ultrasound and strain ratio USE before surgery. Ultrasonographic features were analysed separately and together as ultrasound score, to assess sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Receiver operating characteristic (ROC) curves to identify optimal cut-off value of the strain ratio were also provided. Diagnosis on a surgical specimen was considered the standard of reference. RESULTS: Higher strain ratio values were found in malignant nodules, with an optimum strain ratio cut-off of 2.09 at ROC analysis. USE with strain ratio showed 90.6% sensitivity, 93% specificity, 82.8% PPV, 96.4% NPV, while US score yielded a sensitivity of 52.9%, specificity of 84.3%, PPV 55.6% and NPV 82.9%. The diagnostic gain with strain ratio was statistically significant as proved by ROC areas, which was 0.9182 for strain ratio and 0.6864 for US score. CONCLUSIONS: USE with strain ratio should be considered a useful additional tool to colour-Doppler US, since it improves characterisation of thyroid nodules with indeterminate cytology. KEY POINTS: • Strain ratio measurements improve differentiation of thyroid nodules with indeterminate cytology • Elastography with strain ratio is more reliable than ultrasound features and ultrasound score • Strain ratio may help to better select patients with Thy 3 nodules candidate for surgery.

EVAR: Benefits of CEUS for monitoring stent-graft status.

Endo vascular aortic repair [EVAR] is performed with low peri-operative morbidity and mortality rate and short hospital stay. However, EVAR needs a close and lifelong imagining surveillance for a timely detection of possible complications including endoleaks, graft migration, fractures, and enlargement of aneurysm sac size with eventual rupture. Contrast enhanced computed tomography [CTA] is actually considered the gold-standard in EVAR follow-up, but it is accompanied with radiation burden and renal injury due to the use of contrast media. In the last two decades several studies have shown the role of contrast enhanced ultrasound [CEUS] in post-EVAR surveillance, with very good diagnostic performance, absence of renal impairment, and no radiation, accompanied by low costs, in comparison with CTA. In numerous prospective studies and meta-analyses the detection and characterization of endoleaks with CEUS is comparable to that of CTA imaging. Nowadays, in the EVAR surveillance novel strategies which involve CEUS with a central role, are suggested by several authors and applied in many institutions. In this review article we will present a comprehensive overview and analyses of the literature on the CEUS state-of-art imagining of EVAR follow-up, with its technique, findings, diagnostic accuracy, and its role in the follow up program.

Strain US Elastography for the Characterization of Thyroid Nodules: Advantages and Limitation.

Thyroid nodules, with their high prevalence in the general population, represent a diagnostic challenge for clinicians. Ultrasound (US), although absolutely reliable in detecting thyroid nodules, is still not accurate enough to differentiate them into benign and malignant. A promising novel modality, US elastography, has been introduced in order to further increase US accuracy. The purpose of this review article is to assess the thyroid application of US strain elastography, also known as real-time elastography or quasistatic elastography. We provide a presentation of the technique, and of up-to-date literature, analyzing the most prominent results reported for thyroid nodules differentiation. The practical advantages and limitations of strain elastography are extensively discussed herein.

Q-elastosonography of solid thyroid nodules: assessment of diagnostic efficacy and interobserver variability in a large patient cohort.

OBJECTIVE: Evaluation of the diagnostic efficacy and interobserver agreement of Q-elastography in the differentiation of benign from malignant thyroid nodules. METHODS: A total of 344 thyroid nodules in 288 patients were examined with grey-scale and colour Doppler ultrasound (CDUS) and Q-elastography by two independent operators. Nodules with hypoechogenicity, poorly defined margins, microcalcifications, and intralesional vascularity were classified as suspicious. Diagnostic performances of CDUS features and Q-elastography for predicting thyroid malignancy were estimated using ROC analysis. Cytology or histopathology was the reference standard. Interobserver agreement in the evaluation of CDUS and Q-elastography was assessed using Cohen's k-statistic. RESULTS: Q-elastography showed excellent diagnostic performance for the prediction of thyroid malignancy, with sensitivity of 93 % and specificity of 92 % for operator 1 (best cutoff at 2.02), and sensitivity of 84 % and specificity of 79 % for operator 2 (best cutoff at 1.86). Performance of Q-elastography was superior to that of CDUS. Reproducibility of the findings was excellent for both Q-elastography and CDUS features as assessed with Cohen's k, which was highest for strain ratio measurements (0.95) and lowest for the echogenicity score (0.83). CONCLUSIONS: Q-elastography showed excellent performance. It is a valid and reproducible diagnostic method as well as a promising tool for identifying suspicious solid thyroid nodules needing cytological assessment and surgery. KEY POINTS: • Elastography is an additional tool for optimal characterisation of malignant thyroid nodules. • The use of semiquantitative elastographic evaluation increases the diagnostic performance, • The interobserver agreement of quantitative elastography can be considered to be good.

Metastatic signet ring cell carcinoma presenting as a thyroid diffuse involvement: report of a case studied with Q-elastographic and acoustic radiation force impulse imaging features.

Metastatic carcinomas to the thyroid are rare in daily clinical practice. However, when encountered they represent a diagnostic challenge, since it is difficult to distinguish them from primary thyroid lesions, especially when occurring in patients with occult malignant history. Nevertheless, it is critical to differentiate a metastatic tumor from primary thyroid lesions, as the clinical management and the prognosis are different for the two entities. More recently, elastosonography opened new possibilities to ultrasound in different fields, such as thyroid nodule differentiation. Herein, we report a case of metastatic signet ring cell carcinoma to the thyroid studied with quantitative elastography and acoustic radiation force impulse imaging.

Ultrasound evaluation of liver fibrosis: preliminary experience with acoustic structure quantification (ASQ) software.

PURPOSE: The aim of our study was to assess the diagnostic accuracy of acoustic structure quantification (ASQ) ultrasound software in estimating the degree of hepatic fibrosis compared to Fibroscan and liver biopsy. MATERIALS AND METHODS: Seventy-seven patients with chronic viral hepatitis B and C underwent standard ultrasound examination, ASQ, Fibroscan and liver biopsy. ASQ analysis was conducted by placing a single region of interest (ROI) on each image captured, and calculating mode, average and standard deviation. The sonographic technique was developed through a preliminary evaluation of 20 healthy volunteers. RESULTS: The area under the receiver operating characteristic (AUROC) curve for the diagnosis of cirrhosis (F≥4) with ASQ was 0.77, whereas for the diagnosis of any degree of fibrosis (F≥1) it was 0.71. The AUROC for the diagnosis of cirrhosis (F≥4) with Fibroscan was 0.98, while for the diagnosis of any degree of fibrosis (F≥1) it was 0.94. The difference between the AUROC was statistically significant (p<0.05). CONCLUSIONS: ASQ is a promising new ultrasound software programme which offers encouraging results in the diagnosis of both liver cirrhosis (F=4) and fibrosis (F≥1). However, to date it has not attained the same level of diagnostic performance as Fibroscan.

Prospective evaluation in 123 patients of strain ratio as provided by quantitative elastosonography and multiparametric ultrasound evaluation (ultrasound score) for the characterisation of thyroid nodules.

PURPOSE: This study was done to compare quantitative elastosonography and ultrasound analysis in the characterisation of thyroid nodules. MATERIALS AND METHODS: From July 2009 to September 2011, 123 patients with 147 thyroid nodules were included in our study. All patients enrolled had to undergo thyroidectomy because of nodular thyroid disease (goitre or nodules). After preliminary examination with conventional ultrasound (US) and colour Doppler US, the patients were examined with elastosonography, using high-level equipment (Toshiba Aplio XG) and quantitative software (Elasto-Q). Each lesion was characterised using an US score (echogenicity, borders, microcalcifications and colour Doppler pattern), and then by elastosonographic strain ratio. Each patient subsequently underwent thyroidectomy. Histological results were used as the gold standard. RESULTS: Histological examination demonstrated 89 benign and 58 malignant lesions. On average, the strain ratio value was 2.84±2.69 (range, 0.05-14.5; p=0.001). Sensitivity and specificity of the US score were about 56% and 72%, respectively, whereas those of the strain ratio were 93% and 89%, using a cut-off of 2 obtained with receiver operating characteristic (ROC) curve analysis. Elastosonography was more accurate than US and colour Doppler US in characterising thyroid nodules (p=0.002). CONCLUSIONS: Quantitative elastosonography is a useful diagnostic tool in the evaluation of thyroid lesions, and can be used to limit fine-needle aspiration cytology and improve the selection of patients for thyroidectomy.

Prospective evaluation of multiparametric ultrasound and quantitative elastosonography in the differential diagnosis of benign and malignant thyroid nodules: preliminary experience.

PURPOSE: To assess the clinical value of quantitative elastosonography compared with multiparametric ultrasound in differentiating the nature of thyroid nodules. METHODS AND MATERIALS: Ninety-seven consecutive patients (32 males, 65 females, mean age, 54 years, range 20-81 years) with thyroid nodules previously detected at color-Doppler ultrasound (CDUS), were prospectively examined with elastosonography with dedicated quantitative software (Elasto-Q, Toshiba) before surgery. Ultrasound examination and elastosonography were evaluated by two investigators in consensus. US features, color-Doppler pattern, and strain ratio value were evaluated. Sensitivity and specificity of CDUS and sono-elastography were compared using X(2) test and ROC curves. RESULTS: Sensitivity and specificity of hypoechogenicity, irregular margins or suspicious halo features, CDUS blood flow pattern, and strain ratio in the diagnosis of malignant nodules were 56.8%, 62.2%, 54.1% and 97.3% and 71.7%, 93.3%, 28.3%, and 91.7%, respectively. Elastosonography was more sensitive and specific than all ultrasonographic features in predicting malignancy of the thyroid nodules (p<0.0001). According to elastosonographic features the lesions characterized by strain ratio ≥ 2 were highly likely to be of malignant nature (p<0.0001, O.R. 396, 95%, CI: 44-3530). CONCLUSIONS: The results of the present study suggest that elastosonography with Q system is a valuable tool in the characterization of thyroid nodules and it seems to be far more accurate than CDUS. These findings as well as those of previous studies support its use in selecting patients who are candidates for surgery.