Hydrodissection and programmed stop sedation in 100 % of benign thyroid nodules treated with radiofrequency ablation.

PURPOSE: To describe our group experience in treatment of benign symptomatic thyroid nodules using radiofrequency ablation technique always associated to routine pre-procedure hydrodissection and under sedation with programmed stop. METHODS: Dual-center, retrospective study conducted between April 2018 and January 2020. A total of 52 symptomatic benign thyroid nodules were treated in 34 patients with ultrasound-guided percutaneous radiofrequency ablation. The technique of choice was moving-shot technique and 100 % patients underwent pre-procedural hydrodissection with 5% glucose solution, plus conscious sedation with programmed stop during procedure. RESULTS: Most nodules were solid or almost completely solid (n = 45, 88.3 % of nodules), followed by cystic composition (n = 4, 7.8 %) and mixed (n = 2, 3.9 %). As for location, most were on the right lobe (n = 29, 56.9 %), followed by the left lobe (n = 17, 33.3 %) and isthmus (n = 5, 9.8 %). The average volume of nodules before ablation was 18.2 ±â€¯20.5 mL. Volumetric reduction rates at one, three, six and twelve months after ablation were 46.6 %, 64.5 %, 76.1 % and 88.8 %, respectively. No complications strictly related to procedure were reported. No more than 5 min were added to total time of ablative treatment considering routine hydrodissection and stop programmed sedation. CONCLUSIONS: Minimally invasive therapies applied to thyroid allow the preservation of healthy thyroid parenchyma and provide a very effective volumetric reduction of symptomatic benign thyroid nodules. Hydrodissection with 5 % glucose solution, conscious sedation and patient stimulation with programmed stop during procedure may provide greater safety to procedure, and, in our experience, could be done routinely in all patients.

Penile emergencies: a review of the main conditions.

Acute penile conditions, which typically have a traumatic, vascular, or infectious etiology, are rather uncommon and often require prompt medical evaluation. Penile emergencies can be treated conservatively or surgically, and their management often relies on the results of imaging examinations. Because of its high spatial resolution and wide availability, as well as the fact that it does not involve the use of ionizing radiation, ultrasound is the imaging modality of choice in the initial evaluation of penile emergencies. Inconclusive cases can be further evaluated with magnetic resonance imaging. The main purpose of this pictorial essay is to review the main penile emergencies, by presenting illustrative cases, focusing on radiologic findings, and discussing the roles played by the various imaging methods.

As condições agudas do pênis são raras, geralmente relacionadas a causas traumáticas, vasculares ou infecciosas, e muitas vezes requerem avaliação médica imediata. As emergências penianas podem ter tratamento conservador ou cirúrgico e muitas vezes dependem dos exames de imagem. A ultrassonografia é a modalidade de imagem de escolha na avaliação inicial das emergências penianas, em virtude da alta resolução espacial, ampla disponibilidade e ausência de radiação ionizante desse método. A ressonância magnética deve ser considerada em casos inconclusivos, oferecendo maior campo de visão e detalhes precisos sobre o local e extensão das lesões. O principal objetivo deste ensaio iconográfico é revisar as principais emergências do pênis por meio de casos ilustrativos, com foco nos achados radiológicos e no papel dos métodos de imagem.

Image-guided percutaneous renal cryoablation: Five years experience, results and follow-up.

OBJECTIVES: To describe the experience of our institution in image-guided renal nodules percutaneous cryoablation, evaluating demographic and technical aspects as well as efficacy, safety and follow up. MATERIALS AND METHODS: Retrospective study approved by our institutional review board. Seventy-one renal tumors evaluated in 60 patients treated with image guided percutaneous renal cryoablation from January 2009 to December 2015. No patient was excluded from study, even those who were lost on follow up. All the procedures were guided both by ultrasound and tomography. An argon and helium based cryoablation machine was used for all treatments. Hydrodissection was performed when the bowel or ureters were within 1 cm (iodinated contrast media in dextrose solution). Complications were assessed by the terminology criteria of the National Institutes of Health (NIH). Patients were monitored and evaluated by ultrasound, tomography, MRI and/or PET-CT. RESULTS: In most procedures (91.9%) only one nodule was treated. Nodules had a median size of 1.6 cm. Most nodules (61,9%) were exophytic. Hydrodissection and retrograde warm pyeloperfusion were performed in most procedures. Among all variables evaluated in univariate analysis, nearness of nodule to collecting system and anterior/posterior location were significantly associated with PRCA complications. No other factor evaluated was significantly associated with complications. CONCLUSION: PRCA is solid alternative to traditional surgical therapies for treatment of small renal tumors in wide subset of patients. Medium term evidence shows excellent long-term oncological results, similar to nephrectomy, with minimal risk of major complications.

Fine needle aspiration biopsy of thyroid nodule smaller than 1.0 cm: accuracy of TIRADS classification system in more than 1000 nodules.

OBJECTIVE: To identify whether or not the same ultrasound features can be applied and should be considered to support the decision as to which subcentimeter nodules should be biopsied with fine needle aspiration (FNAB). METHODS: Single-institution, IRB approved, retrospective study conducted from 2008 to 2016 that evaluated 1094 thyroid nodules smaller than 1.0 cm that were classified according to TIRADS and submitted for FNAB. RESULTS: The value of FNAB of thyroid nodules smaller than 1.0 cm were assessed and correlated with the sonographic criteria by comparing the obtained results with the cytological findings in 1094 thyroid nodules. In the analysis considering all nodules, the proportion of malignancies among nodules with TIRADS 2 is 0.91% and for TIRADS 3 is 2.87%. Among those classified as 4A, 12.26%; with 4B classification, 34.43%; with 4C classification, 66.6%; and among those with 5 classifications, 85.7%. CONCLUSION: In conclusion, the TIRADS classification system, based on the sonographic features reported herein, may help detect which nodules should be investigated for potential malignancies. Advances in knowledge: Few reports compare the efficacy of ultrasound-FNAB for thyroid nodules smaller than 1.0 cm in diameter. The findings of malignancy in this subgroup of nodules may help in the clinical follow-up of which patients should be submitted to an early imaging evaluation or intervention.

Prostate cancer recurrence in vas deferens - fusion image guide as an important tool in dignosis.

The biochemical recurrence after local treatment for prostate cancer is an often challenging condition of clinical management. The aim of this report is to demonstrate the importance of the association of various imaging methods in the identification and subsequent accurate percutaneous biopsy in patients with recurrence of prostate cancer, especially in unusual sites. An 86 years old male with biochemical recurrence, during radiological investigation a PET-MRI was noted the presence of an asymmetry of the vas deferens with PSMA- 68Ga uptaken, suggesting the recurrence. A percutaneous fusion biopsy with PET-MRI and ultrasound was performed using transrectal access using ultrasound confirming infiltrating adenocarcinoma of the wall of the vas deferens, compatible with neoplastic prostate recurrence. The fusion image technique combines the real-time view of the US to the possibility of higher definition and higher specificity, methods more anatomical detail as tomography and magnetic resonance imaging, simultaneously. High resolution acquired in PET / MR associated with image fusion allows orientation procedures, even in areas of difficult access, with greater accuracy than conventional techniques.

Advances in lung ultrasound.

Ultrasound examination of the chest has advanced in recent decades. This imaging modality is currently used to diagnose several pathological conditions and provides qualitative and quantitative information. Acoustic barriers represented by the aerated lungs and the bony framework of the chest generate well-described sonographic artifacts that can be used as diagnostic aids. The normal pleural line and A, B, C, E and Z lines (also known as false B lines) are artifacts with specific characteristics. Lung consolidation and pneumothorax sonographic patterns are also well established. Some scanning protocols have been used in patient management. The Blue, FALLS and C.A.U.S.E. protocols are examples of algorithms using artifact combinations to achieve accurate diagnoses. Combined chest ultrasonography and radiography are often sufficient to diagnose and manage lung and chest wall conditions. Chest ultrasonography is a highly valuable diagnostic tool for radiologists, emergency and intensive care physicians. RESUMO O exame ultrassonográfico do tórax avançou nas últimas décadas, sendo utilizado para o diagnóstico de inúmeras condições patológicas, e fornecendo informações qualitativas e quantitativas. Os pulmões aerados e o arcabouço ósseo do tórax representam barreira sonora para o estudo ultrassonográfico, gerando artefatos que, bem conhecidos, são utilizados como ferramentas diagnósticas. Eco pleural normal, linhas A, linhas B, linhas C, linhas E e Z (conhecidas como falsas linhas B) são artefatos com características peculiares. Os padrões de consolidação e de pneumotórax também são bem estabelecidos. Alguns protocolos têm sido utilizados no manuseio dos pacientes: Blue Protocol, Protocolo FALLS e Protocolo C.A.U.S.E são exemplos de três propostas que, por meio da associação entre os artefatos, permitem sugerir diagnósticos precisos. A ultrassonografia de tórax, aliada à radiografia de tórax, muitas vezes é suficiente para o diagnóstico e a conduta das afecções pulmonares e da parede torácica. Trata-se de ferramenta diagnóstica de grande valia para médicos radiologistas, emergencistas e intensivistas.

Computed Tomography-Guided Percutaneous Thoracic Duct Sclero-Embolization for Persistent Chylothorax.

Postoperative chylous leak is often a consequence of thoracic duct injury during surgical procedures. Persistent chylothorax can be an extremely morbid condition. The authors describe a case of a refractory and long-standing chylous leak after thoracotomy for mediastinal lymphangioma removal. The patient was treated with a computed tomography-guided percutaneous thoracic duct sclero-embolization after failure of the conventional therapies. The chest tube output abruptly decreased after the procedure and was removed at 13th day. Percutaneous thoracic duct sclero-embolization proved to be safe and effective in the treatment of a persistent chylothorax.

Correlation of Thyroid Imaging Reporting and Data System [TI-RADS] and fine needle aspiration: experience in 1,000 nodules.

OBJECTIVE: To correlate the Thyroid Imaging Reporting and Data System (TI-RADS) and the Bethesda system in reporting cytopathology in 1,000 thyroid nodules. METHODS: A retrospective study conducted from November 2011 to February 2014 that evaluated 1,000 thyroid nodules of 906 patients who underwent ultrasound exam and fine needle aspiration. RESULTS: A significant association was found between the TI-RADS outcome and Bethesda classification (p<0.001). Most individuals with TI-RADS 2 or 3 had Bethesda 2 result (95.5% and 92.5%, respectively). Among those classified as TI-RADS 4C and 5, most presented Bethesda 6 (68.2% and 91.3%, respectively; p<0.001). The proportion of malignancies among TI-RADS 2 was 0.8%, and TI-RADS 3 was 1.7%. Among those classified as TI-RADS 4A, proportion of malignancies was 16.0%, 43.2% in 4B, 72.7% in 4C and 91.3% among TI-RADS 5 (p<0.001), showing clear association between TI-RADS and biopsy results. CONCLUSION: The TI-RADS is appropriate to assess thyroid nodules and avoid unnecessary fine needle aspiration, as well as to assist in making decision about when this procedure should be performed. OBJETIVO: Apresentar a correlação entre o Thyroid Imaging Reporting and Data System (TI-RADS) e o sistema Bethesda, para relatar citopatologia em 1.000 nódulos tireoidianos. MÉTODOS: Estudo retrospectivo realizado no período de novembro de 2011 a fevereiro de 2014, que avaliou 1.000 nódulos tireoidianos de 906 pacientes submetidos a exame de ultrassonografia e à punção aspirativa por agulha fina. RESULTADOS: Observou-se associação significativa entre o TI-RADS e o resultado da classificação de Bethesda (p<0,001). A maioria dos indivíduos com TI-RADS 2 ou 3 teve resultado citológico Bethesda 2 (95,5% e 92,5%, respectivamente). Entre aqueles classificados TI-RADS 4C e 5, a maioria teve resultado Bethesda 6 (68,2% e 91,3%, respectivamente; p<0,001). A proporção de malignidades em TI-RADS 2 foi 0,8% e em TI-RADS 3 foi 1,7%. Entre TI-RADS 4A, foi de 16,0%, 43,2% em 4B, 72,7% em 4C e em 5 foi de 91,3% (p<0,001), mostrando clara associação entre o TI-RADS e os resultados da biópsia. CONCLUSÃO: O TI-RADS é apropriado para avaliar nódulos da tireoide e evitar punção aspirativa por agulha fina desnecessária, além de auxiliar na decisão sobre quando este procedimento deve ser realizado.

Percutaneous Cholecystostomy and Hydrodissection in Radiofrequency Ablation of Liver Subcapsular Leiomyosarcoma Metastasis Adjacent to the Gallbladder: Protective Effect.

Uterine leiomyosarcoma is an uncommon pathology, predominantly found in aged population. Patients with metastatic disease have poor survival and therapy mainly consists of palliative systemic chemotherapy. However, more aggressive strategies such as radiofrequency ablation (RFA) may benefit patients with limited secondary disease. RFA is considered a simple and safe modality for treatment of hepatic lesions. The benefits related to RFA include low morbidity, short hospital stay and the possibility to repeat the procedure when necessary due to recurrences. However, minor and major complications related to mechanical and thermal damage may occur, especially in cases of tumors adjacent to extrahepatic organs and those at subcapsular position. This case report shows a successful RFA of two hepatic subcapsular leiomyosarcoma metastases neighbouring the gallbladder, without a safe cleavage plane from it. Combined hydrodissection, percutaneous cholecystostomy and continuous irrigation were performed as effective techniques to prevent thermal injury. Clinical and radiological follow up demonstrates no local complication.

Percutaneous CT-Guided Ablation in the Hepatic Dome: Artificially Induced Pneumothorax for Safe Transpleural Access.

Ablative therapies have become a great alternative to surgical treatment of hepatic nodules. Some technical difficulties may negatively influence the effectiveness of this therapy, such as lesions located near the diaphragm. The transthoracic approach is commonly used to access these lesions. However, it is associated with an increased risk of complications, such as pneumothorax, hemothorax, alveolar bleeding, and others. We report a case of a radiofrequency ablation of a lesion in the hepatic dome, where an artificially induced pneumothorax was performed to guarantee a safe and effective access. The air was easily injected by a spinal needle and later aspirated by a single-lumen catheter. Induced pneumothorax shoud be considered in ablation of hepatic dome lesions, mainly when the transhepatic access is not appropriate.