Multimodal ultrasonography evaluation in thyroid nodule characterization: what is the ideal algorithm?

AIMS: The aim of this study is to investigate the diagnostic performances of Ultrasonography (US), Shear-wave Elastography (SWE), and Superb Microvascular Imaging (SMI) findings in the diagnosis of malignant thyroid nodules (MTNs) and to determine the US algorithm with the best diagnostic performance. MATERIAL AND METHODS: Eighty-one nodules in 77 patients who had underwent multimodal US with biopsy results, were evaluated. Echogenicity, nodule components, contours, presence and type of calcification, and size were analyzed with US. Nodule stiffness and vascular index (VI) measurements were performed via SWE and SMI. The power of the US algorithm in predicting malignancy was evaluated. RESULTS: Hypoechogenicity, irregular contour, aspect ratio (anteroposterior (AP)/transvers diameter) >1, and >43.9 kPa were the characteristicshad significant efficacy in the diagnosis of MTNs. Sensitivity, specificity, and AUC values were respectively 100%, 48.5%, and 0.742 for hypoechogenicity; 80%, 90.1%, and 0.855 for irregular contour; 60%, 71.2%, and 0.656 for aspect ratio >1; 60%, 72.7%, and 0.671 for >43.9 kPa; and 93.3%, 90.9%, and 0.921 for the US algorithm. VI did not show significant efficacy in diagnosis. CONCLUSION: Some B-mode and SWE findings showed sufficient efficacy in differentiating benign and malign nodules on their own. However, diagnostic accuracy increased significantly when the US algorithm was applied.

Effects of fat accumulation in the liver on hemodynamic variables assessed by Doppler ultrasonography.

PURPOSE: To investigate the effect of various degrees of fatty liver infiltration on hepatic hemodynamics using Doppler ultrasonography. METHODS: We included 40 patients with hepatic steatosis and 20 healthy volunteers. Hepatic steatosis was quantified by a chemical shift MRI. Hepatic artery peak systolic and end-diastolic velocity, resistance index (RI) and pulsatility index (PI), hepatic vein RI and PI, portal vein RI, PI, congestion index, and peak maximum velocity were evaluated by Doppler ultrasonography. The hepatic vein waveforms were classified as triphasic, biphasic, or monophasic. Kruskal-Wallis test was performed for comparing more than two groups. If significant differences were found, Mann-Whitney U test with Bonferroni correction was performed for pair-wise comparisons. Pearson &gch;(2) and Fisher's exact tests were used to compare categorical variables. RESULTS: According to MRI, 15 patients had mild, 14 patients had moderate, and 11 patients had severe fatty infiltration. Portal vein peak maximum velocity was median: 19.8 (range 12-33.3), 21.1 (8-41.8), 16.6 (10.6-24.9), and 29.2 (14.1-40.4) cm/s. Congestion index was 0.05 (0.02-0.16), 0.07 (0.01-0.17), 0.11 (0.06-0.24), and 0.05 (0.02-0.16). Hepatic artery RI was 0.75 (0.56-1.00), 0.66 (0.52-0.87), 0.83 (0.38-1.00), and 0.76 (0.48-2.76), and PI was 1.83 (0.90-3.13), 1.38 (1.04-2.63), 1.97 (0.86-2.90), and 1.82 (0.70-2.90) (p = .046 and p = .036) in the mild, moderate, severe steatosis, and control groups, respectively. The rate of triphasic hepatic vein waveforms was higher in controls than in patients with severe steatosis. CONCLUSIONS: Portal vein flow velocity decreases in severe hepatic steatosis when compared with controls.

Early graft dysfunction and mortality rate in marginal donor liver transplantation.

BACKGROUND/AIM: To determine the effect of marginal donor livers on mortality and graft survival in liver transplantation (LT) recipients. MATERIALS AND METHODS: Donors with any 1 of following were considered marginal donors: age ≥65 years, sodium level ≥ 165 mmol/L and cold ischemia time ≥ 12 h. Donors were classified according to the donor risk index (DRI) < 1.7 and ≥ 1.7. The transplant recipients' model for end-stage liver disease (MELD) scores were considered low if < 20 and high if ≥ 20. Early graft dysfunction (EGD) and mortality rate were evaluated. RESULTS: During the study period 47 patients underwent cadaveric LT. The mean age of the donors and recipients was 45 years (range: 5-72 years) and 46 years (range: 4-66 years), respectively. In all, there were 15 marginal donors and 18 donors with a DRI > 1.7. In total, 4 LT patients that received livers from marginal donors and 5 that received livers from donors with a DRI ≥ 1.7 had EGD. Among the recipients of marginal livers, 5 died, versus 4 of the recipients of standard livers. There was no significant difference in EGD or mortality rate between the patients that received livers from marginal donors or those with a DRI ≥ 1.7 and patients that received standard donor livers. CONCLUSION: Marginal and DRI ≥ 1.7 donors negatively affected LT outcomes, but not significantly.

The role of diffusion-weighted MRI in the classification of liver hydatid cysts and differentiation of simple cysts and abscesses from hydatid cysts.

PURPOSE: The purpose of this study is to identify the role of diffusion-weighted magnetic resonance imaging (DW-MRI) in the classification of liver hydatid cysts (HCs) and their differentiation from simple cysts and liver abscesses. MATERIALS AND METHODS: Twenty-two patients that were sent to our department with preliminary diagnoses of HCs or abscess were included in the study. Thirty lesions were evaluated. MRI included T1-weighted fast gradient echo, T2-weighted half-Fourier acquisition single-shot turbo spin echo, and DW single-shot echo planar pulse sequencing (b, 0, 50, and 1000 s/mm²). The apparent diffusion coefficient (ADC) values (mm²/s) of the HCs, abscesses, and simple cysts were calculated. RESULTS: No statistically significant difference was found between the ADC values of type 1 and 3 (P > 0.05) HCs and of simple cysts and type 1 HCs (P > 0.05). The ADC values of abscesses were significantly lower than those of type 1 and type 3 HCs, and simple cysts. No statistically significant difference was found between the ADC values of abscesses and type 4 HCs (P > 0.05). Type 4 lesions exhibited significantly lower ADC values in comparison to type 1 and 3 HCs. CONCLUSION: DW-MRI helps differentiate type 4 lesions from other cysts and can distinguish abscesses from hydatid cysts other than type 4 as well as from simple cysts. Type 1 HCs cannot be differentiated from simple cysts using ADC values alone, and type 4 lesions are indistinguishable from abscesses.

The clinical value of incidental 18F-fluorodeoxyglucose-avid foci detected on positron emission tomography/computed tomography.

OBJECTIVE: This study was performed to show the malignant potential and clinical value of incidental focal 18F-fluorodeoxyglucose (18F-FDG) uptake on positron emission tomography/computed tomography (PET/CT) with the confirmation of histopathologic findings or with a series of consequent correlative imaging methods. METHODS: A total of 2370 18F-FDG-PET/CT studies performed over a 16-month period in patients with various malignant diseases were retrospectively reviewed. Unexpected PET foci that were in an unusual site for metastatic spread of known malignancy and not considered to be physiologic uptake were evaluated by histopathologic findings or follow-up with correlative imaging methods for a period of 1 year or longer. There were 121 such incidental PET lesions in 116 patients. RESULTS: Seventy-four incidental PET lesions in 70 PET/CT patients were investigated further. Forty-seven lesions in 46 patients were lost to follow-up. Fifty-nine lesions were confirmed histopathologically. Fifteen lesions were evaluated with radiologic methods or instrumental examination. Thirty-six incidental PET foci were unexpected malignant or premalignant lesions (1.5% of 2370 patients and 49% of 74 PET foci). Nineteen of these 36 malignant or premalignant lesions were synchronous carcinomas, 14 lesions were unusual or unexpected malignant spread of known malignancy and three lesions were premalignant colonic adenomas. Thirty-three of 74 incidental PET lesions were of benign origin (1.4% of 2370 patients and 44% of 74 PET foci). Five PET foci were false-positive findings (7% of 74 lesions). CONCLUSION: The detection of incidental 18F-FDG-PET foci on PET/CT may reflect unexpected malignant lesions related to unusual malignant spread of primary malignancy or synchronous tumor. Follow-up of these PET foci may result in significant change in therapy management and early diagnosis of various abnormalities that require a medical approach or surgical intervention.

MR imaging in the detection of diffuse axonal injury with mild traumatic brain injury.

PURPOSE: To evaluate the occurrence and distribution of mild traumatic brain injury (MTBI) caused by diffuse axonal injury (DAI) using magnetic resonance (MR) imaging and to attempt to correlate MR findings with post-concussion symptoms (PCS). PATIENTS AND METHODS: Forty MTBI patients (mean age: 32.5 years) with normal cranial computed tomography (CT) findings were examined with standard MR protocol including T(1)-weighted, T(2)-weighted, fluid attenuated inversion recovery (FLAIR), gradient echo (GRE) and diffusion-weighted (DW) sequences. MR imaging was performed within 24 hours of injury. The lesions were classified as DAI based on their location and morphologic appearance. RESULTS: In MR imaging of five (12.5%) of the patients, the lesions compatible with DAI were observed. Four patients (10%) had the foci of low signal intensity compatible with hemorrhagic shear injury on the GRE sequence, and five (12.5%) patients had high signal intensity on FLAIR and DW sequence. CONCLUSION: MR imaging can be helpful in revealing DAI lesions in patients with normal CT scan findings after MTBI. FLAIR, GRE and DW sequences are superior to conventional spin-echo images in detecting DAI lesions.

The role of Doppler sonography in predicting severity of acute pancreatitis.

PURPOSE: To investigate the role of Doppler sonography (DUS) examination of major abdominal arteries in predicting severity of acute pancreatitis (AP). METHODS: Twenty-nine patients diagnosed with AP and 14 controls were blindly and prospectively evaluated with Doppler sonography. Disease severity was defined clinically according to acute physiology and chronic health evaluation (APACHE II) score and was classified as severe for APACHE II score > or =8. DUS examination included the measurement of peak systolic velocity (PSV), end diastolic velocity (EDV), pulsatility index (PI), and resistance index (RI) of the celiac artery (CA) and superior mesenteric artery (SMA). Statistical analysis included Mann-Whitney U test, Student t test, and receiver operating characteristic curve analysis. RESULTS: Twelve patients had severe AP and 17 had mild AP. PSV, EDV, and PI of the CA and RI of the SMA were higher in the severe AP group than in the mild AP and control groups (p < 0.001 and p < 0.0001, respectively). The sensitivity and specificity were 100% and 94%, respectively, for a 87 cm/second CA PSV cutoff value, 75% and 100%, respectively, for a 22 cm/second CA EDV cutoff value, 92% and 82%, respectively, for a 1.29 CA PI cutoff value, and 100% and 100%, respectively, for a 0.86 SMA RI cutoff value. CONCLUSION: DUS can be useful in predicting the severity of AP in the early period of admission phase of the disease.

Secondary aortoenteric fistula in a patient with Behçet disease: successful surgical treatment by direct suture and use of omental flap.

The aim of this report is to present a patient with Behçet disease who developed massive lower gastrointestinal tract bleeding owing to aortoenteric fistula after abdominal aorta graft reconstruction. A 34-year-old male with a history of Behçet disease for 8 months underwent surgery owing to massive hematochezia and hemodynamic instability. A fistula was observed between the proximal small intestinal segment and the aortic graft (proximal anastomosis) at the infrarenal level. The prosthesis was not removed but was wrapped with the vascularized pedicle of the omentum that passed through the mesentery of the transverse colon. The patient was discharged on the fifty-ninth day. At the 15-month follow-up appointment, the patient was in excellent condition. Although our surgical choice was not a standard approach for this type of aortoenteric fistula, it was a lifesaving procedure in our patient.

Relationship between the arterial calcification detected in mammography and coronary artery disease.

OBJECTIVE: Arterial calcification is frequently encountered in mammography. The frequency of breast arterial calcification (BAC) increases with increasing age. Studies have shown that BAC is seen more frequently among the people who are under the risk of coronary artery diseases (CAD) such as diabetes and hypertension. The objective of this study is to investigate the relationship between the arterial calcification detected in mammography and the CAD. MATERIAL AND METHODS: Screening mammography was performed in 123 women above the age of 40 years who had been examined with coronary angiography for the evaluation of CAD. The presence of BAC, number of affected vessels, and the distribution of calcification in the vessel wall were evaluated in the mammography. Subjects were questioned in terms of the cardiovasculary risk factors. The severity of CAD was evaluated according to the Gensini scoring. In addition, the number of blood vessels with stenosis of more than 50% was used as the vascular score. The correlation between Gensini and the vascular scores, and BAC was statistically evaluated using Mann-Whitney U and Kruskal-Wallis tests. RESULTS: Eighty (65%) of 123 patients had CAD. BAC was detected in the mammography of 49 (39.8%) subjects. The ages and duration of menopause of the cases with BAC were significantly higher than those without BAC (p<0.001). There was an almost significant correlation between the BAC and Gensini scores (p=0.059). There was a significant increase in the frequency of BAC among subjects with more than two vessels with stenosis (p=0.033). CONCLUSION: Frequency of BAC increases with increasing age. BAC is also frequently seen in subjects having severe coronary artery disease. Although increasing age may be a factor increasing the frequency of BAC, BAC may also be an indicator of CAD. Therefore, the mentioning of arterial calcification in mammography reports may be important in warning the clinician in terms of CAD.

Giant spigelian hernia due to abdominal wall injury: a case report.

Spigelian hernia is a rare clinical entity. It is difficult to diagnose due to its location. In this article we report the case of a giant spigelian hernia consequent to abdominal wall injury. The neck of the hernia was 10 cm in diameter. We repaired this hernia with a polypropylene mesh.

Effects of hormone replacement therapy regimens on mammographic breast density: the role of progestins.

AIM: To evaluate the effects of different regimens of hormone replacement therapy (HRT) on mammographic breast density. METHODS: Mammograms of 113 healthy postmenopausal women who were on different HRT regimens were evaluated retrospectively. All women had a baseline mammography and at least one mammogram after at least 12 months of HRT. Four parenchymal patterns were considered mammographically. Quantification of density changes that occurred on follow-up mammograms was done qualitatively and with reference to densities on baseline mammograms. RESULTS: Sixty women were treated with a continuous estrogen-progestin combination; 16 with a cyclic estrogen-progestin combination and 37 were with estrogen only. Twenty-six women had increased mammographic density after HRT. Mammographic density increase was detected in 23 women (38.3%) of the continuous estrogen-progestin combination group, two women (12.5%) of the cyclic estrogen-progestin combination group and one woman (2.7%) of the estrogen-only group. Mammographic density increase was more common among women in the continuous estrogen-progestin combination group than the other groups and this difference was found to be statistically significant (P < 0.001). Breast density increase was observed in 18 of 30 women (60%) with higher doses of progestin compared to 5 of 30 women (16.7%) with lower dose (P < 0.05). CONCLUSIONS: Postmenopausal HRT may increase mammographic breast density. Breast density appears to be mostly affected by higher doses and continuous administration of progestin.