The Significance of Contrast-Enhanced Ultrasound in the Application of Lymphaticovenous Anastomosis.

BACKGROUND: Lymphaticovenous anastomosis (LVA) surgery is an effective treatment for lymphedema. Accurate evaluation and localization of the superficial lymphatic vessels before the operation is crucial for the success of the operation. Contrast-enhanced ultrasound (CEUS) is a new ultrasound technology, and its clinical application value in LVA surgery has not been established. OBJECTIVE: This study aimed to assess the efficacy of CEUS in LVA surgery and provide a novel approach for the clinical assessment and localization of superficial lymphatic vessels. METHODS: Retrospective analysis of imaging and surgical data was performed on 20 LVA patients. Among them, 10 cases underwent evaluation and localization using indocyanine green (ICG) lymphatic imaging (Group A), while 10 cases were evaluated and localized using CEUS (Group B). The differences in surgical data between the two groups were compared and analyzed. RESULTS: All 20 patients were female (mean age, 57.7 years ± 6.3 [SD]). CEUS demonstrated superior visualization and localization of superficial lymphatic vessels. The average diameter of lymphatic vessels identified in the CEUS group was significantly greater than that in the ICG group (0.78±0.06 vs. 0.52±0.05mm; P<0.001). The duration of operation in group B was significantly shorter than that in group A (4.47±0.37 vs. 6.70±0.45mm; P<0.001). The number of anastomosed lymphatic vessels in group B was less than that in group A [5.0(4.0, 6.0) vs. 9.5 (9.0, 11.3); P<0.001]. CONCLUSION: CEUS can serve as a viable alternative to ICG lymphatic imaging, facilitating improved lymphatic venous anastomosis surgery.

Ultrasound image-based deep learning to assist in diagnosing gross extrathyroidal extension thyroid cancer: a retrospective multicenter study.

Background: The presence of gross extrathyroidal extension (ETE) in thyroid cancer will affect the prognosis of patients, but imaging examination cannot provide a reliable diagnosis for it. This study was conducted to develop a deep learning (DL) model for localization and evaluation of thyroid cancer nodules in ultrasound images before surgery for the presence of gross ETE. Methods: From January 2016 to December 2021 grayscale ultrasound images of 806 thyroid cancer nodules (4451 images) from 4 medical centers were retrospectively analyzed, including 517 no gross ETE nodules and 289 gross ETE nodules. 283 no gross ETE nodules and 158 gross ETE nodules were randomly selected from the internal dataset to form a training set and validation set (2914 images), and a multitask DL model was constructed for diagnosing gross ETE. In addition, the clinical model and the clinical and DL combined model were constructed. In the internal test set [974 images (139 no gross ETE nodules and 83 gross ETE nodules)] and the external test set [563 images (95 no gross ETE nodules and 48 gross ETE nodules)], the diagnostic performance of DL model was verified based on the pathological results. And then, compared the results with the diagnosis by 2 senior and 2 junior radiologists. Findings: In the internal test set, DL model demonstrated the highest AUC (0.91; 95% CI: 0.87, 0.96), which was significantly higher than that of two senior radiologists [(AUC, 0.78; 95% CI: 0.71, 0.85; P < 0.001) and (AUC, 0.76; 95% CI: 0.70, 0.83; P < 0.001)] and two juniors radiologists [(AUC, 0.65; 95% CI: 0.58, 0.73; P < 0.001) and (AUC, 0.69; 95% CI: 0.62, 0.77; P < 0.001)]. DL model was significantly higher than clinical model [(AUC, 0.84; 95% CI: 0.79, 0.89; P = 0.019)], but there was no significant difference between DL model and clinical and DL combined model [(AUC, 0.94; 95% CI: 0.91, 0.97; P = 0.143)]. In the external test set, DL model also demonstrated the highest AUC (0.88, 95% CI: 0.81, 0.94), which was significantly higher than that of one of senior radiologists [(AUC, 0.75; 95% CI: 0.66, 0.84; P = 0.008) and (AUC, 0.81; 95% CI: 0.72, 0.89; P = 0.152)] and two junior radiologists [(AUC, 0.72; 95% CI: 0.62, 0.81; P = 0.002) and (AUC, 0.67; 95 CI: 0.57, 0.77; P < 0.001]. There was no significant difference between DL model and clinical model [(AUC, 0.85; 95% CI: 0.79, 0.91; P = 0.516)] and clinical + DL model [(AUC, 0.92; 95% CI: 0.87, 0.96; P = 0.093)]. Using DL model, the diagnostic ability of two junior radiologists was significantly improved. Interpretation: The DL model based on ultrasound imaging is a simple and helpful tool for preoperative diagnosis of gross ETE thyroid cancer, and its diagnostic performance is equivalent to or even better than that of senior radiologists. Funding: Jiangxi Provincial Natural Science Foundation (20224BAB216079), the Key Research and Development Program of Jiangxi Province (20181BBG70031), and the Interdisciplinary Innovation Fund of Natural Science, Nanchang University (9167-28220007-YB2110).

A SOX17-PDGFB signaling axis regulates aortic root development.

Developmental etiologies causing complex congenital aortic root abnormalities are unknown. Here we show that deletion of Sox17 in aortic root endothelium in mice causes underdeveloped aortic root leading to a bicuspid aortic valve due to the absence of non-coronary leaflet and mispositioned left coronary ostium. The respective defects are associated with reduced proliferation of non-coronary leaflet mesenchyme and aortic root smooth muscle derived from the second heart field cardiomyocytes. Mechanistically, SOX17 occupies a Pdgfb transcriptional enhancer to promote its transcription and Sox17 deletion inhibits the endothelial Pdgfb transcription and PDGFB growth signaling to the non-coronary leaflet mesenchyme. Restoration of PDGFB in aortic root endothelium rescues the non-coronary leaflet and left coronary ostium defects in Sox17 nulls. These data support a SOX17-PDGFB axis underlying aortic root development that is critical for aortic valve and coronary ostium patterning, thereby informing a potential shared disease mechanism for concurrent anomalous aortic valve and coronary arteries.

Application of Contrast-enhanced Ultrasound and Bosniak Classification to the Diagnosis of Cystic Renal Masses.

BACKGROUND: The Bosniak classification system based on contrast-enhanced computed tomography (CECT) is commonly used for the differential diagnosis of cystic renal masses. Contrastenhanced ultrasound (CEUS) is a relatively novel technique, which has gradually played an important role in the diagnosis of cystic renal cell carcinoma (CRCC) due to its safety and lowest price. OBJECTIVE: The aim of the study is to investigate the application value of CEUS and Bosniak classification into the diagnosis of cystic renal masses. METHODS: 32 cystic masses from January 2018 to December 2019 were selected. The images of conventional ultrasound (US), CEUS and CECT from subjects confirmed by surgical pathology were retrospectively analyzed. The Bosniak classification system of cystic renal masses was implemented using CEUS and CECT, and the diagnostic ability was compared. RESULTS: For the 32 cystic masses, postoperative pathology confirmed 11 cases of multilocular CRCC, 15 cases of clear cell carcinoma with hemorrhage, necrosis and cystic degeneration, 5 cases of renal cysts, and 1 case of renal tuberculosis. The Bosniak classification based on CEUS was higher than that based on CECT, and the difference was statistically significant (P = .024). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of CEUS were comparable to CECT. There was no significant difference observed in the diagnosis of CRCC (P >.05). CONCLUSION: CEUS combined with Bosniak classification greatly improves the diagnosis of CRCC. CEUS shows a comparable diagnostic ability to CECT. In daily clinical routine, patients who require multiple examinations and present contraindications for CECT can particularly benefit from CEUS.

Contrast-enhanced Ultrasound for Diagnosis of Renal Cystic Mass.

BACKGROUND: Cystic Renal Cell Carcinoma (CRCC) is often difficult to differentiate from complex cysts with sonographic manifestations of renal carcinoma. Contrast-Enhanced Ultrasound (CEUS) is a new technology, and its clinical utility in the diagnosis of renal cystic mass has not been established. OBJECTIVE: The objective of this study is to analyze the characteristics of CEUS of renal cystic masses and to explore the clinical significance and value of CEUS in the diagnosis of CRCC. METHODS: This study was a retrospective study. A total of 32 cystic masses from January 2018 to December 2019 were selected. The images of conventional Ultrasound (US) and CEUS were confirmed via surgical pathology. Routine US was used to observe the location, shape, size, boundary, cyst wall, internal echo, and blood supply of each cystic mass. CEUS observed contrast enhancement of the cyst wall, cystic septa, and solid nodules of cystic masses. RESULTS: There were 26 cases of CRCC, 5 cases of renal cysts, and 1 case of renal tuberculosis. The enhancement pattern, degree of enhancement, and pseudocapsular sign by CEUS in benign and malignant masses had statistically significant differences (P<.05). In the diagnosis of CRCC, the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 92.3%, 83.3%, 90.6%, 96.0%, and 71.4% for CEUS; 57.6%, 66.7%, 59.3%, 88.2%, and 26.7% for conventional US, respectively. CEUS had a higher sensitivity and accuracy than the conventional US (P<.05), although the diagnostic specificity, positive predictive value and negative predictive value of the two methods were not significantly different (P>.05). CONCLUSION: CEUS is more accurate in the diagnosis of renal cystic masses, and it can be used as an effective imaging method.

Diagnosis of liver tumors by multimodal ultrasound imaging.

To investigate the diagnostic value of multimodal ultrasound imaging composed of conventional ultrasonography (US), contrast-enhanced ultrasonography (CEUS), and shear wave elastography (SWE) for liver tumors.Between October 2017 and October 2019, US, CEUS, and SWE examinations of a total of 158 liver tumors in 136 patients at The First Affiliated Hospital of Nanchang University were performed. The histopathological or imaging diagnostic results were used as controls to evaluate the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of US, CEUS, SWE, and multimodal ultrasound imaging, which combines these 3 modes, in the differential diagnosis of benign and malignant liver tumors.Among the 158 tumors, there were 64 benign tumors, including 55 cases of hepatic hemangioma, 3 cases of focal nodular hyperplasia of the liver, 4 cases of hepatic cyst, and 2 cases of focal nonuniform distribution of fat in the liver. There were 94 malignant tumors, including 32 cases of hepatocellular carcinoma, 22 cases of intrahepatic cholangiocellular carcinoma, 29 cases of metastatic liver cancer, and 11 cases of dysplastic nodules in cirrhotic liver. In the diagnosis of benign and malignant liver tumors, the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 82.56%, 68.06%, 75.96%, 75.53%, and 76.56% for US; 92.39%, 86.36%, 89.87%, 90.43%, and 89.06% for CEUS; 87.14%, 76.81%, 82.91%, 82.98%, and 82.81% for SWE; and 97.85%, 95.38%, 96.83%, 96.81%, and 96.88% for multimodal ultrasound imaging, respectively. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were all significantly higher for multimodal ultrasound imaging than those values for US, CEUS, and SWE (all P < .05). The areas under the receiver operating characteristic curve for US, CEUS, SWE, and multimodal ultrasound imaging in the diagnosis of benign and malignant liver tumors were 0.760, 0.897, 0.829, and 0.968, respectively.US, CEUS, and SWE all have diagnostic value in the diagnosis of benign and malignant liver tumors. Multimodal ultrasound imaging could significantly increase the accuracy of the diagnosis of benign and malignant liver tumors and has higher value for clinical application.

Echocardiographic diagnosis of anomalous origin of the left coronary artery from the pulmonary artery.

The aim of this research is to investigate the application value of TTE in the diagnosis of the anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA).The echocardiographic findings of 11 patients with ALCAPA confirmed by surgery in our hospital from October 2007 to December 2018 were retrospectively analyzed and compared with the preoperative computed tomography angiography (CTA) diagnosis and intraoperative diagnosis.Surgery was performed in all of the patients to establish the dual coronary artery system. Four underwent the Takeuchi procedure and 7 had re-implantation of the anomalous left coronary artery. The CTA diagnoses of the 11 patients were consistent with the surgical diagnoses, and the diagnostic accuracy was 100% (11/11). Echocardiographic diagnosis showed consistent results in 10 cases, while one case was misdiagnosed as endocardial fibroelastosis; the diagnostic accuracy was 90.9% (10/11). The echocardiographic features of these patients with ALCAPA included: abnormal left coronary ostium arising from the pulmonary trunk with retrograde coronary artery flow in 10 patients; enlargement of the right coronary artery in 8 patients; abundant intercoronary septal collaterals in 6 patients; and moderate and significant mitral regurgitation in 7 patients. Echocardiography showed that the left ventricular end-diastolic diameter and left ventricular end-systolic diameter before surgery were significantly different from those after surgery (P < .05) and that the left ventricular ejection fraction and fractional shortening before surgery were not significantly different from those after surgery (P > .05).Transthoracic echocardiography can diagnose ALCAPA in a timely, accurate, and noninvasive manner, and it could be of great significance in guiding clinical operations and in predicting prognosis.

Diagnosis of infective endocarditis using echocardiography.

The aim of this study was to evaluate the application of transthoracic echocardiography for the diagnosis of infective endocarditis (IE) to provide a basis for the better treatment of IE. From October 2016 to October 2018, 87 consecutive patients with IE at our hospital were selected for this study. All the patients were subjected to transthoracic echocardiography. The morphology, structure, activity, and closure of the patients' heart valves were observed for vegetation identification, and the size, number, location, morphology, and echo intensity of vegetation, as well as degree of valve involvement, were determined.The 87 patients investigated in this study included 38 cases of congenital heart disease, 27 cases of nonrheumatic valvular heart disease, 12 patients who underwent valve surgery, 5 cases of rheumatic valvular heart disease, and 5 patients with no obvious signs of heart disease. The most common clinical manifestations were heart murmur in 80 cases and fever in 60 cases. The most common complications were heart failure in 35 cases, followed by organ embolism in 12 cases. There were 36 cases of positive blood cultures, including 26 cases of Gram-positive cocci and 10 cases of Gram-negative bacilli. Echocardiography showed aortic valve involvement in 37 cases, mitral valve involvement in 34 cases, tricuspid valve involvement in 10 cases, pulmonary valve involvement in 2 cases, and the involvement of an artificial valve in 5 cases. Twenty-six of these cases showed multiple valve involvement, and 20 patients exhibited serious complications. No significant differences were found between echocardiography and actual surgical observations with respect to their accuracy in detecting the size, number, and location of vegetation in the 69 patients who underwent surgery (P > .05). Echocardiography could detect the occurrence of severe complications, namely, the rupture of chordae tendineae, valve prolapse, valve perforation, and paravalvular abscess, and no significant difference in diagnostic accuracy was found between echocardiography and surgical observations (P > .05).Transthoracic echocardiography can rapidly and accurately detect IE vegetation and its complications and has important clinical value for guiding clinical treatment and determining prognosis.

Diagnosis of mitral valve cleft using real-time 3-dimensional echocardiography.

BACKGROUND: Mitral valve cleft (MVC) is the most common cause of congenital mitral insufficiency, and MVC may occur alone or in association with other congenital heart lesions. Direct suture and valvuloplasty are the major and effective treatments for mitral regurgitation (MR) caused by MVC. Therefore, it is important to determine the location and magnitude of the pathological damage due to MVC when selecting a surgical procedure for treatment. This study explored the application value of transthoracic real-time 3-dimensional (3D) echocardiography (RT-3DE) in the diagnosis of MVC. METHODS: From October 2012 to June 2016, 19 consecutive patients with MVC diagnosed by 2-dimensional (2D) echocardiography in our hospital were selected for this study. Full-volume RT-3DE was performed on all patients. The 3D-imaging data were cropped and rotated in 3 views (horizontal, sagittal, and coronal) with 6 directions to observe the position and shape of the MVC and the spatial position between the cleft and its surrounding structures. The maximum longitudinal diameter and the maximum width of the cleft were measured. The origin of the mitral regurgitant jet and the severity of MR were evaluated, and these RT-3DE data were compared with the intraoperative findings. RESULTS: Of the 19 patients studied, 4 patients had isolated cleft mitral valve, and cleft mitral valves combined with other congenital heart lesions were detected in 15 patients. The clefts of 6 patients were located in the A2 segment, the clefts of 4 patients were located in the A1 segment, the clefts of 4 patients were located in the A3 segment, the clefts of 4 patients were located in the A2-A3 segment, and the cleft of 1 patient was located in the P2 segment. Regarding the shape of the cleft, 13 patients had V-shaped clefts, and the others had C- or S-shaped clefts. The severity of the MR at presentation was mild in 2 patients, moderate in 9 and severe in 8. Two of the patients with mild MR did not undergo surgery, while the remaining 17 patients did undergo surgery. Surgical treatment involved direct suture in 11 cases, reconstruction with ring annuloplasty in 3 cases and replacement in 3 cases. The diagnoses of MVC were confirmed by intraoperative findings. RT-3DE successfully captured full-volume 3D images of the 19 patients, which directly displayed the 3D structure of MVC with multiple views such as the position, shape, longitudinal diameter and width of the MVC, and the spatial position between the chordae tendineae surrounding the MVC and the aortic valve. The maximum longitudinal diameter of the valve leaflet cleft measured by RT-3DE and direct measurements during surgery were 12.02±2.12 and 13.01±2.45 mm, respectively, and the difference between these measurements was not statistically significant (P>0.05). Our results indicate that RT-3DE can provide more direct, accurate and abundant information. CONCLUSIONS: RT-3DE is a simple and fast imaging technique, and the detailed 3D images obtained can be used to confirm the diagnosis of MVC. RT-3DE is considered to be an important preoperative test that provides more comprehensive information for selecting a subsequent procedure for treatment.