Ultrasound evaluation in the postoperative period for surgical treatment of thoracic infectious and inflammatory diseases.

OBJECTIVE: This study aims to evaluate the role of TUSG in the postoperative period and the detection of early complications after surgical treatment, pulmonary resection, or decortication for infectious and inflammatory thoracic diseases, comparing with the standard method (Chest Radiography ‒ CXR). METHODS: Prospective non-randomized self-controlled study. Twenty-one patients over 16 years of age have undergone surgical treatment of inflammatory and infectious lung diseases. These patients were followed up with CXR and TUSG (performed on the 1st and 3rd postoperative days and/or after the chest tube removal). RESULTS: Both exams demonstrated similar results regarding their ability to safely predict the adequate moment for chest drain removal. TUSG allowed chest drain removal in 30% of cases and CXR in 34%. Statistical analysis demonstrates that both exams have similar capabilities in detecting postoperative changes in the pleural space. However, the authors report that TUSG is statistically more accurate in detecting subcutaneous emphysema than CXR (p = 0.037, Kappa [κ = 0.3068]). The analysis of other parameters showed no statistical difference. CONCLUSION: The authors conclude that TUSG in trained hands is equivalent to CXR in searching for postoperative complications regarding the surgical treatment of infectious and inflammatory thoracic diseases and can be used as a complement, and not a substitute, to CXR, when CCT is not feasible, or a more urgent diagnosis is needed.

Vesicoureteral reflux by contrast ultrasound, comparison with voiding and retrograde urethrocystography: A prospective accuracy study.

INTRODUCTION: Diagnosis of vesicoureteral reflux (VUR) plays an important role in the management and follow-up of children presenting with urinary tract infection. This study compared voiding uronosography (VUS) as a diagnostic method for the diagnosis of VUR with the "gold standard", voiding or micturating cystourethrography (MCU). The objective of the study is not only to compare the effectiveness of both methods, but also to assess the feasibility of implementing VUS technically and economically in a large tertiary radiology center in South America. MATERIALS AND METHOD: This was a prospective accuracy study that include 41 patients (a total of 85 ureteral units) aged between 1 month and 16 years. VUS was performed in an alternative form as regular MCU, by injecting microbubble contrast solution (SonoVue©) into the bladder through an intermittent catheter and evaluating the presence of reflux with ultrasound. MCU was always performed immediately after VUS. One pediatric radiologist evaluated all VUS exams, while a second independent pediatric radiologist evaluated all MCU exams, with both blinded to each other's assessments. RESULTS: Comparing VUS with MCU in the diagnosis of VUR, we observed a sensitivity of 92.3 % (95 % CI 74.9-99.1 %), specificity of 98.3 % (95 % CI 90.9-100 %), positive predictive value of 96.0 % (95 % CI 79.6-99.9 %), negative predictive value of 96.7 % (95 % CI 88.5-99.6 %) and a Kappa of 0.916 (0.822-1.000). When comparing the VUR grading between VUS and MCU the agreement between the two methods was high with a Kendall's Tau-b > 0.9. VUS failed to diagnose two grade 1 VUR reflux cases in teenagers while diagnosing one grade 4 VUR in a very dilated kidney-ureter unit, which was missed on MCU. VUS and MCU had similar costs when considering the price of the ultrasound contrast agent. DISCUSSION: VUS is a reliable alternative method to MCU for the diagnosis of VUR with the advantages of not exposing the child to ionizing radiation and potentially being more accessible due to the greater availability of ultrasound equipment. Limitations to this study include the usage of a single ultrasound equipment, which limits its generalizability and not evaluating the interobserver variability. CONCLUSION: Consideration should be given to implementing VUS for the diagnosis of VUR, particularly in centers without fluoroscopy equipment available, since the exam's performance and cost are comparable to those of the MCU.

Ultrasound in cervical traumatic neuromas after neck dissection in thyroid carcinoma patients: descriptive analysis and diagnostic accuracy.

Objective: Cervical traumatic neuromas (CTNs) may appear after lateral neck dissection for metastatic thyroid carcinoma. If they are misdiagnosed as metastatic lymph nodes (LNs) in follow-up neck ultrasound (US), unnecessary and uncomfortable fine-needle aspiration biopsy are indicated. The present study aimed to describe US features of CTNs and to assess the US performance in distinguishing CTNs from abnormal LNs. Subjects and methods: Retrospective evaluation of neck US images of 206 consecutive patients who had lateral neck dissection as a part of thyroid cancer treatment to assess CTN´s US features. Diagnostic accuracy study to evaluate US performance in distinguishing CTNs from abnormal LNs was performed. Results: Eight-six lateral neck nodules were selected for analysis: 38 CTNs and 48 abnormal LNs. CTNs with diagnostic cytology were predominantly hypoechogenic (100% vs. 45%; P = 0.008) and had shorter diameters than inconclusive cytology CTNs: short axis (0.39 cm vs. 0.50 cm; P = 0.03) and long axis (1.64 cm vs. 2.35 cm; P = 0.021). The US features with the best accuracy to distinguish CTNs from abnormal LNs were continuity with a nervous structure, hypoechogenic internal lines, short/long axis ratio ≤ 0.42, absent Doppler vascularization, fusiform morphology, and short axis ≤ 0.48 cm. Conclusion: US is a very useful method for assessing CTNs, with good performance in distinguishing CTNs from abnormal LNs.

Ultrasonography in the Assessment of Tumors of the Cheek: Water Mouth Distension Technique.

PURPOSE: To describe a new B-mode ultrasound examination technique to assess cheek tumors. MATERIALS AND METHODS: 30 cheek oral cavity lesions of different histological types (11 benign and 19 malignant) from 23 patients (11 women and 12 men, 7-82 years old, mean age of 49.5 years) were analyzed. Transcutaneous oral B-mode ultrasound (5-12 MHz transducer) was carried out in two stages. Initially it was performed conventionally with an empty mouth. Next, the patient was asked to keep their oral cavity filled with water (like when using a mouthwash) during imaging for the new test examination technique. The anatomical layers of this region and the characteristics of the tumors were evaluated. Lesions were classified as ill defined, partially defined, or defined. Conventional findings were compared to those of the new technique using the Wilcoxon signed-rank test. Ultrasound results were compared to histological findings analyzed by an independent team. RESULTS: The conventional empty mouth technique was able to confidently define lesion extension in only 6 of the 30 lesions, while the water-filled mouth technique was able to confidently define lesion extension in 29 of the 30 lesions (p<0.00001). CONCLUSION: We present a novel technique that dramatically improves ultrasound staging of cheek oral cavity tumors. In addition to the increase in ultrasound accuracy, this technique does not require any special equipment or extra cost, is very well tolerated by patients, and thus should be considered in the evaluation of every patient undergoing transcutaneous cheek ultrasound for oral cavity lesion characterization.

Ultrasound in cervical traumatic neuromas after neck dissection in thyroid carcinoma patients: descriptive analysis and diagnostic accuracy

ABSTRACT Objective: Cervical traumatic neuromas (CTNs) may appear after lateral neck dissection for metastatic thyroid carcinoma. If they are misdiagnosed as metastatic lymph nodes (LNs) in follow-up neck ultrasound (US), unnecessary and uncomfortable fine-needle aspiration biopsy are indicated. The present study aimed to describe US features of CTNs and to assess the US performance in distinguishing CTNs from abnormal LNs. Subjects and methods: Retrospective evaluation of neck US images of 206 consecutive patients who had lateral neck dissection as a part of thyroid cancer treatment to assess CTN's US features. Diagnostic accuracy study to evaluate US performance in distinguishing CTNs from abnormal LNs was performed. Results: Eight-six lateral neck nodules were selected for analysis: 38 CTNs and 48 abnormal LNs. CTNs with diagnostic cytology were predominantly hypoechogenic (100% vs. 45%; P = 0.008) and had shorter diameters than inconclusive cytology CTNs: short axis (0.39 cm vs. 0.50 cm; P = 0.03) and long axis (1.64 cm vs. 2.35 cm; P = 0.021). The US features with the best accuracy to distinguish CTNs from abnormal LNs were continuity with a nervous structure, hypoechogenic internal lines, short/long axis ratio ≤ 0.42, absent Doppler vascularization, fusiform morphology, and short axis ≤ 0.48 cm. Conclusion: US is a very useful method for assessing CTNs, with good performance in distinguishing CTNs from abnormal LNs.

How to Identify Cervical Traumatic Neuromas in the Post-operative Neck Dissection: Brief Review of the Cervical Plexus Ultrasound.

Cervical traumatic neuromas (CTNs) are a non-neoplastic hyperplasia of damaged nerves and may be misinterpreted as metastatic lymph nodes during cervical ultrasound of patients with thyroid cancer after lateral neck dissection, resulting in unnecessary and painful fin-needle aspiration biopsy. The anatomy of the cervical plexus is challenging, and the correct identification and recognition of its neural roots and branches on ultrasound are key to the correct CTN diagnosis. This review outlines the US technique used to characterize CTNs in 10 standardized steps and describes the sonographic features of the cervical plexus, to assist the radiologist in the recognition of CTNs and their differentiation from lymph node metastases.

Contrast-Enhanced Ultrasound Features of Histopathologically Proven Hepatocellular Carcinoma in the Non-cirrhotic Liver: A Multicenter Study.

Current literature on the role of contrast-enhanced ultrasound (CEUS) in the diagnosis of hepatocellular carcinoma (HCC) in non-cirrhotic patients is limited. The aim of this retrospective multicenter study was to analyze CEUS features of histologically proven HCC in patients with non-cirrhotic liver. In this multicenter study, 96 patients from eight medical institutions with histologically proven HCC lesions in non-cirrhotic liver were retrospectively reviewed regarding SonoVue-enhanced CEUS features. Two ultrasound experts assessed the CEUS enhancement pattern and came to a consensus using the World Federation of Societies for Ultrasound in Medicine and Biology guideline criteria. The mean size of HCC lesions included was 60.3 ± 37.8 mm (mean ± standard deviation). Most of the lesions were heterogeneous but predominantly hypo-echoic on B-mode ultrasound (64.5%, 62/96), with ill-defined margins and irregular shapes. During the arterial phase of CEUS, most of the HCC lesions in non-cirrhotic liver exhibited heterogeneous hyperenhancement (78.1%, 75/96) compared with the surrounding liver parenchyma. Almost 30% of HCC lesions (28.1%, 27/96) exhibited early wash-out (<60 s). All lesions exhibited wash-out and hypo-enhancement in the late phase. CEUS features of HCC lesions in non-cirrhotic patients typically include hyperenhancement in the arterial phase and relatively rapid wash-out in the portal venous phase, which is different from HCC in cirrhotic livers and more similar to liver metastasis.

Hepatocellular carcinoma in the non-cirrhotic liver.

Liver cirrhosis is an established high-risk factor for HCC and the majority of patients diagnosed with HCC have cirrhosis. However, HCC also arises in non-cirrhotic livers in approximately 20 %of all cases. HCC in non-cirrhotic patients is often clinically silent and surveillance is usually not recommended. HCC is often diagnosed at an advanced stage in these patients. Current information about HCC in patients with non-cirrhotic liver is limited. Here we review the current knowledge on epidemiology, clinical features and imaging features of those patiens.

Contrast-enhanced ultrasonography for the evaluation of malignant focal liver lesions.

In this review, the authors address the analysis of different types of malignant focal liver lesions (FLLs) using contrast-enhanced ultrasonography (CEUS). The specific enhancing patterns of hepatocellular carcinoma, cholangiocarcinoma, and metastases are discussed and exemplified with images. In addition, the use of CEUS in malignant portal vein thrombosis is discussed. The advantages and limitations of CEUS for the analysis of malignant FLLs are also discussed.

Use of contrast-enhanced ultrasound in pediatrics / Utilização da ultrassonografia com contraste de microbolhas na pediatria

Abstract Although contrast-enhanced ultrasound has been shown to provide considerable benefits, particularly in pediatric patients, it is still used relatively rarely in Brazil. It has proven to be a safe technique, and adverse effects are rare. In this review, we address the technique and main applications of contrast-enhanced ultrasound in the pediatric population, including the evaluation of focal liver lesions, abdominal trauma, kidney grafts, liver grafts, bowel loops, and vesicoureteral reflux. It is important for pediatric radiologists to be acquainted with this promising tool, understanding its applications and limitations.

Resumo A ultrassonografia com contraste de microbolhas é um método ainda pouco utilizado no Brasil, mas que tem grandes vantagens, ainda mais na faixa pediátrica, como ausência de radiação e dispensa de sedação/anestesia. O contraste de microbolhas tem se mostrado bastante seguro e com raríssimas reações adversas graves. Apresentaremos nesta revisão a técnica para o uso desse contraste na ultrassonografia, bem como as principais aplicações na faixa pediátrica, como avaliação das lesões hepáticas focais, do trauma abdominal, do enxerto hepático e renal nos transplantes, das alças intestinais e da pesquisa de refluxo vesicoureteral. É importante que radiologistas que exerçam funções em centros pediátricos conheçam essa ferramenta promissora.

Multiparametric Ultrasound Evaluation of the Thyroid: Elastography as a Key Tool in the Risk Prediction of Undetermined Nodules (Bethesda III and IV)-Histopathological Correlation.

The purpose of this study was to select thyroid nodules most at risk for malignancy among those cytologically undetermined by fine-needle aspiration biopsy (FNAB), using B-mode, color duplex Doppler and 2-D shear wave shear wave elastography (2-D-SWE). This was a prospective diagnostic accuracy study with 62 Bethesda III/IV nodules according to FNAB (atypia/follicular lesion of undetermined significance or follicular neoplasia/Hürthle cell neoplasm). Ultrasonography (US) data were compared with resection histologic results, revealing 35 of 62 benign nodules (56.4%) and 27 of 62 carcinomas (43.6%). Conventional US was uses to evaluate nodule echogenicity, dimensions, contours, presence of halo and microcalcifications. Doppler US was used to assess the vascularization (exclusively or predominantly peripheral or central) and mean resistance index of three nodule arteries. Elastography was used to evaluate the nodule elastographic pattern; mean nodule deformation index; deformation ratio between nodule and adjacent thyroid parenchyma; and mean deformation ratio between nodule and pre-thyroid musculature (MDR). Statistical analysis included χ2, Fisher's exact, Student's t, Mann-Whitney tests and multivariable analysis by multiple logistic regression. Areas under the receiver operating characteristic curves (AUC-ROCs) were used for accuracy analysis. Fifty-eight participants (54.7 ± 14.0 y, 51 women) were studied. The parameters that were statistically significant to the univariate analysis were hypo-echogenicity, nodule diameter greater than width and all parameters analyzed from Doppler and elastography. Multivariate analysis revealed that the MDR (in kPa) was the best parameter for risk analysis of indeterminate nodules. Nodules with MDRs >1.53 exhibited a greater chance of malignancy (AUC-ROC = 0.98). We conclude that 2-D-SWE is able to select malignant nodules among those cytologically indeterminate, thus avoiding unnecessary surgery in these cytologic groups.

Guidelines and Good Clinical Practice Recommendations for Contrast-Enhanced Ultrasound (CEUS) in the Liver-Update 2020 WFUMB in Cooperation with EFSUMB, AFSUMB, AIUM, and FLAUS.

The present, updated document describes the fourth iteration of recommendations for the hepatic use of contrast-enhanced ultrasound, first initiated in 2004 by the European Federation of Societies for Ultrasound in Medicine and Biology. The previous updated editions of the guidelines reflected changes in the available contrast agents and updated the guidelines not only for hepatic but also for non-hepatic applications. The 2012 guideline requires updating as, previously, the differences in the contrast agents were not precisely described and the differences in contrast phases as well as handling were not clearly indicated. In addition, more evidence has been published for all contrast agents. The update also reflects the most recent developments in contrast agents, including U.S. Food and Drug Administration approval and the extensive Asian experience, to produce a truly international perspective. These guidelines and recommendations provide general advice on the use of ultrasound contrast agents (UCAs) and are intended to create standard protocols for the use and administration of UCAs in liver applications on an international basis to improve the management of patients.

Ultrasound elastography in patients with fatty liver disease.

Hepatic steatosis, or fatty liver disease, occurs due to the accumulation of lipids in hepatocytes. When it becomes chronic, lobular inflammation develops and the disease can evolve to hepatic fibrosis, liver cirrhosis, or hepatocellular carcinoma. Early diagnosis is desirable because patients diagnosed in the early stage of the disease respond better to treatment. In the early stages of fatty liver disease, the physical examination is often unremarkable. Fatty liver disease and hepatic fibrosis can be diagnosed and monitored through laboratory tests, imaging, and biopsy. Among the imaging methods, ultrasound stands out as an effective means of diagnosing and following patients with liver disease. Ultrasound used in conjunction with elastography (ultrasound elastography) has recently shown great utility in the follow-up of such patients. Ultrasound elastography studies the degree of deformation (stiffness) of an organ or lesion, so that when there is hardening, fibrosis, or cirrhosis of the liver, those alterations are well demonstrated. In this review article, we discuss the application of the different types of ultrasound elastography for liver studies: transient elastography, point shear wave elastography, and two-dimensional shear wave elastography. Although magnetic resonance elastography may also be used in the analysis of liver fibrosis, it will not be addressed in this article.

Ultrasound elastography in patients with fatty liver disease / Análise da elastografia por ultrassonografia em pacientes com esteatose hepática

Abstract Hepatic steatosis, or fatty liver disease, occurs due to the accumulation of lipids in hepatocytes. When it becomes chronic, lobular inflammation develops and the disease can evolve to hepatic fibrosis, liver cirrhosis, or hepatocellular carcinoma. Early diagnosis is desirable because patients diagnosed in the early stage of the disease respond better to treatment. In the early stages of fatty liver disease, the physical examination is often unremarkable. Fatty liver disease and hepatic fibrosis can be diagnosed and monitored through laboratory tests, imaging, and biopsy. Among the imaging methods, ultrasound stands out as an effective means of diagnosing and following patients with liver disease. Ultrasound used in conjunction with elastography (ultrasound elastography) has recently shown great utility in the follow-up of such patients. Ultrasound elastography studies the degree of deformation (stiffness) of an organ or lesion, so that when there is hardening, fibrosis, or cirrhosis of the liver, those alterations are well demonstrated. In this review article, we discuss the application of the different types of ultrasound elastography for liver studies: transient elastography, point shear wave elastography, and two-dimensional shear wave elastography. Although magnetic resonance elastography may also be used in the analysis of liver fibrosis, it will not be addressed in this article.

Resumo Esteatose hepática ocorre pelo acúmulo de lipídios nos hepatócitos, sua cronificação cursa com inflamação lobular e evolui com fibrose hepática, cirrose e carcinoma hepatocelular. O diagnóstico precoce do acometimento hepático é desejável em razão da melhor resposta terapêutica dos pacientes na fase inicial da doença. O exame físico nas fases iniciais da doença não apresenta alterações. O diagnóstico e o controle evolutivo da esteatose e fibrose hepática podem ser realizados por exames laboratoriais, exames de imagens e biópsia. Entre os exames de imagem, destaca-se a ultrassonografia (US) no diagnóstico e acompanhamento dos pacientes com doença hepática. Atualmente, a US associada à elastografia vem se destacando para acompanhamento desses pacientes. A elastografia por US estuda o grau de deformação (ou dureza) do órgão ou lesão, de modo que quando há endurecimento do fígado, por fibrose ou cirrose, essa alteração é bem demonstrada na elastografia por US. Neste artigo de revisão nos propusemos a discutir a aplicação dos diversos tipos de elastografia por US para estudo do fígado: elastografia transitória, point-shear wave elastography e 2D-shear wave elastography. A elastografia por ressonância magnética também pode ser utilizada na análise de fibrose hepática, mas não será abordada neste artigo.

Laser Ablation of Benign Thyroid Nodules: A Prospective Pilot Study With a Preliminary Analysis of the Employed Energy.

BACKGROUND AND OBJECTIVES: To assess the effectiveness of ultrasound (US)-guided laser ablation of benign thyroid nodules (TNs) under different amounts of applied energy. STUDY DESIGN/MATERIALS AND METHODS: Thirty-four euthyroid patients with 5-18 ml TNs were enrolled: 21 (laser ablation) and 13 (clinical follow up) patients with a mean age of 56.2 ± 12.0 and 54.7 ± 14.7 years, respectively. The laser ablation protocol used a 1.064 mm wavelength diode laser source; 3.5 W output power; 1,100-1,500 J and 5-8 min/illumination; and one or two fibers/session. Clinical, laboratory, and US data were obtained immediately before treatment and at 6 and 12 months follow-up and were analyzed by Student's t test and Fisher's exact test. Low- and high-energy subgroups were subsequently defined, and the receiver operating characteristic (ROC) curves were calculated. RESULTS: Laser ablation follow-up showed an overall nodule volume reduction of more than 50%; improvement of symptoms and cosmetic complaints (P = 0.001); and stable laboratory data compared with the baseline and control groups. Minor complications were 9.5% ( n = 2). One or two fibers/session resulted in a similar nodule volume reduction among 10-18 ml nodules. Analysis of the applied energy suggested a 398.8 J/ml inferior cutoff (ROC curve: 0.889 sensitivity; 0.545 specificity) for the high-energy subgroup ( n = 14, mean 599.9 ± 136.5 J/ml) to reduce the nodule volume over time (-55.1% vs. -58.4%, P = 0.55). The low-energy subgroup ( n = 7, mean 240.2 ± 74.6 J/ml) did not show a persistent volume reduction ( P < 0.05) from the 6- to 12-month follow-ups (-56.6% vs. -53.7%). CONCLUSIONS: Laser ablation of benign TNs achieved technique efficacy at 12 months posttreatment, with clinical improvement and few minor side effects. A single fiber in a single session with a high deployed energy (>398.8 J/ml) may be associated with improved results, a finding to be confirmed with a larger series. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.