Multiple metastasis of malignant melanoma. The diagnostic role of ultrasonography starting from a parotid tumor.

We presented the case of a patient with a slowly developing right parotid tumor over the course of several years. Multimodal ultrasonography proved relevant for malignancy. Subsequent imaging identified tumors in numerous organs, considered metastases. Ultrasonography consolidated all identified aspects. Biopsy from an adrenal mass and histological examination evidenced the presence of a malignant, metastatic melanoma with cutaneous origin. Considerations are made regarding the role of ultrasonography in such cases.

Greyscale and contrast enhanced ultrasonography for characterization of gastric malignant tumors.

AIMS: To evaluate the utility of grey scale ultrasonography (US) and contrast enhanced ultrasonography (CEUS) for characterization of malignant gastric tumors. MATERIAL AND METHODS: The study was conducted prospectively and it included a number of 30 patients with malignant gastric tumors diagnosed through upper tract endoscopy and biopsy: 25 adenocarcinomas, 3 lymphomas, and 2 stromal tumors. All the patients were examined by US, followed immediately by CEUS, using both oral and intravenous contrast agents. CEUS assessed the dynamics of the contrast agent during the arterial phase and the venous phase. The distribution characteristics of the contrast agent inside the region of interest (ROI) were also evaluated. Twenty four patients underwent surgery. RESULTS: Adenocarcinomas presented heterogeneous enhancement with variable pattern, followed by a delayed wash-out in almost all of the situations. Lymphomas presented a variable pattern, intensity and homogeneity of the enhancement, followed by delayed wash-out. Stromal tumors showed early arterial intense and homogenous enhancement followed by moderate wash-out in venous phase. CONCLUSIONS: Grey scale US and CEUS are useful methods in characterizing gastric tumors and contribute to a more adequate evaluation of the lesions. The dynamics of the contrast agent may be suggestive for the anatomopathological nature of the tumor. Larger studies will be necessary in order to determine thepractical value of the method.

The value of ultrasound diagnosis in the multidisciplinary approach of cutaneous tumours. Case report.

We report the case of a senior patient, presenting with two cutaneous tumours in which the clinical and dermoscopic examination pointed towards a basal cell carcinoma. Ultrasound revealed highly vascularised tumours and elastography showed increased rigidity. Histological examination of both lesions following complete resection was consistent with squamous cell carcinomas. The distinctive feature of this case consists of the complex non-invasive diagnostic imaging of the tumour morphology, performed in real time, revealing aspects compatible with highly proliferative malignant tumours. This case emphasises the importance of ultrasound diagnosis in a multi-disciplinary approach for better and more predictable results.

Using dynamic infrared thermography to optimize color Doppler ultrasound mapping of cutaneous perforators.

AIMS: The high technical demands associated with perforator flaps demand a precise preoperative identification and evaluation of perforator vessels. Color Doppler Ultrasonography (CDU) and Dynamic Infrared Thermography (DIRT) are currently used for preoperative perforator mapping. Each individual technique has advantages and disadvantages. The purpose of this paper is to analyze the value of combining the two methods in order to optimize the process of preoperative perforator mapping. MATERIAL AND METHODS: CDU and DIRT were used for preoperative perforator mapping in 10 pigs. The results were compared to intraoperative findings. Total number of perforators, localization, and identification of the dominant perforator was analyzed for each method. The examination time was recorded for each procedure. RESULTS: Both methods had a high sensitivity in determining the number and localization of perforators when compared to those identified during surgery. DIRT produced a higher number of false positive results. CDU accurately identified the emergence of the perforators in the fascia in all cases. Both methods correctly identified the dominant perforator. The sensitivity, positive predictive value, and accuracy of CDU were 93.56%, 97%, and 91.30% respectively and for DIRT 95.05%, 80.67%, and 77.41% respectively. The average examination was 39.76 minutes for CDU and 10.24 minutes for DIRT. The average time taken into account for the analysis of a single perforator in order to confirm DIRT findings was 1.83 minutes. CONCLUSIONS: Preoperative perforator mapping has become a compulsory step in nearly all reconstructive procedures. In our study, both CDU and DIRT correctly identified the dominant perforator in all cases. By combining the two examinations overall mapping time can be reduced significantly. A reduced examination time translates into increased patient compliance and a lower procedure cost. The combined mapping technique facilitates the selection of the ideal perforator in all cases. Correctly identifying the dominant perforator preoperatively reduces operative time, lowers complication rates and ensures an overall better result.

Oral and I.V. contrast enhanced ultrasonography of the digestive tract--a useful completion of the B-mode examination: a literature review and an exhaustive illustration through images.

Contrast enhanced ultrasonography, using i.v. and/or oral/rectal contrast agents, represents a technical development of the US method, which has proved its applicability in the qualitative and quantitative assessment of the normal and pathological circulatory bed, as well as of the digestive lumen. The use of microbubbles and harmonics opens a new horizon in the detection and characterization of the inflammatory and tumoral conditions of the digestive tract. The interpretation of the data requires corroboration with the grey scale aspect of the examined lesion/area, as well as with the clinical context of the case and the results of other diagnosis techniques. The purpose of this paper is to review the main applications of CEUS in digestive tract pathology by analyzing the significant literature and guidelines in the light of our personal experience and demonstrating it through suggestive images.

Integrative analysis of cutaneous skin tumours using ultrasonogaphic criteria. Preliminary results.

THE AIM: of this study is to identify the US features of skin tumors, especially morphological and vascular, in order to develop an integrative and differentiating imaging model for benign and malignant skin tumors. MATERIAL AND METHOD: Twenty three patients with solid skin tumors were included in the study. The diagnostic procedures were clinical examination, dermoscopy, multimodal ultrasonography (US), using high frequency and conventional US, contact elastography, and i.v. contrast enhanced ultrasound (CEUS). RESULTS: The US characteristics of the basal cell carcinomas were: hypoechoic, inhomogeneous masses, with hyperechoic or anechoic areas, depending on the histological differentiation, increased rigidity, uneven vascularization at Doppler examination, central or mixed type circulatory model, with 1-2 supply vessels, velocity >2 cm/s, intensely inhomogeneous load of the contrast agent (CA) and quick wash out time. The benign tumors were hypoechoic or echoic masses, with inhomogeneous structure, Doppler signal present only in dermofibromas, peripheral circulation model, velocities < 2.00 cm/s, a weak and uneven loading of the CA in the vascular bed, and a slow wash out time. Analysis of the CA dynamics evidenced a significantly higher value for the wash out time in the malignant tumors (38.2s+/- 15.15) as compared to the benign ones (54.2s +/- 8.5). Particularly the tumor thickness examination by HFUS evidences an ultrasound index that may be considered as a statistically significant predictive factor (p<0.05), highly sensitive (r =0.97) for the non-invasive assessment of the histological Breslow index. Elastography did not represent a differentiation examination in the cases studied. CONCLUSIONS: Ultrasound allows a complex, multimodal approach of skin tumors, which completes clinical and histological examinations, orients the therapeutic management and may assess the therapeutic efficacy and the tumoral prognosis.

Solid parotid tumors: an individual and integrative analysis of various ultrasonographic criteria. A prospective and observational study.

OBJECTIVES: The purpose of the study is to identify and validate ultrasound criteria for parotid tumors evaluation, as well as to elaborate a multimodal, multi-criteria and integrative ultrasound approach for allowing tumor discrimination in a non-invasive manner. MATERIAL AND METHOD: Twenty patients with solid parotid tumors (12 benign, 8 malignant) were examined by ultrasound: real-time "grey scale" ultrasound, Doppler ultrasound, elastography, harmonic ultrasound imaging with i.v. contrast (CEUS). The study focused on tumor morphology and circulation. The analysis of the results was observational, enhanced by statistical methods and artificial intelligence (decision trees). RESULTS: All malignant tumors showed increased hypoechogenicity, tumoral cervical adenopathies, increased stiffness and "in block" mobility with the parotid gland upon palpation with the transducer, uneven distribution of the contrast material during the arterial phase (8/8). To varying degrees, they showed imprecise delineation (7/8), structural heterogeneity (6/8) and disorganized flow pattern (6/8). All cases of benign tumors showed heterogeneous echostructure, clear delineation and no capsule (12). They also showed moderate hypoechogenicity (9/12), no cervical lymph nodes (11/12) and variable rigidity (increased 6/12; low 3/12). A selection and ranking of relevant ultrasound parameters was also made. Some of them were included in a transparent and easy-to-use decision tree model with 100% data accuracy. CONCLUSIONS: The characterization and discrimination of solid parotid tumors require a multimodal and multicriteria approach. Ultrasound criteria can be divided into criteria of certainty and criteria of diagnosis probability. CEUS examination of parotid tumors did not reveal significant differences between benign and malignant circulatory bed. Decision trees discovered by artificial intelligence from the data may represent intelligent diagnosis support systems with very high accuracy, up to 100%.

ARFI quantitative elastography of the submandibular glands. Normal measurements and the diagnosis value of the method in radiation submaxillitis.

OBJECTIVES: Evaluation of Acoustic Radiation Force Impulse Imaging (ARFI) elastography performance in predicting the elasticity of the submandibular glands in normal situations and after radiation therapy. MATERIAL AND METHOD: A number of 54 normal submandibular glands from 27 voluntary subjects and 33 pathological submandibular glands (radiation submaxillities) from 18 patients who had undergone radiation therapy for various cervical and facial oncological conditions were included in study. All the patients had undergone a B mode ultrasonography (Tissue Harmonic Imaging, 8-14 MHz) while the submandibular volume was determined and subsequently an ARFI examination while the shear wave velocity (SWV) was measured (in the central, peripheral and subcapsular areas, with the results expressed in m/s). RESULTS: In the volunteers' group the mean value of the SWV of the left submandibular gland was 1.68 ± 0.46 m/s, determined in the centre of the gland, 1.88 ± 0.4 m/s in the periphery (corresponding to the subcapsular parenchyma) and the SWV of the right submandibular gland was 1.74 ± 0.35 m/s (centrally) and 1.84 ± 0.43 m/s in the periphery. The mean value of all measurements was 1.82 ± 0.41 m/s. The mean volume of the glands was 7.97 ± 2.63 cm3. In the group of patients who had underwent radiation therapy (at least 35Gy), the mean value of the SWV was 2.24 ± 0.49 m/s centrally and 2.1 ± 0.58 m/s in the periphery on the left and 1.99 ± 0.5 m/s centrally and 2.21 ± 0.52 m/s in the periphery on the right. The mean value of all the measurements was 2.13 ± 0.52 m/s and the mean volume of the gland was 5.95 ± 4.16 cm3. CONCLUSIONS: Elastography using ARFI technique is a valid examination in the evaluation of the normal and pathological submandibular gland stiffness. The values of the shear wave velocities that correspond to a normal stiffness, determined through the ARFI technique, are similar in the two glands. After cervical and facial radiation therapy the values of the SWV are increased, indicating a change in the consistency of the gland thus implying a structural transformation. The ARFI technique can be used in the evaluation of the salivary glands pathology.

Fractal analysis of elastographic images for automatic detection of diffuse diseases of salivary glands: preliminary results.

The geometry of some medical images of tissues, obtained by elastography and ultrasonography, is characterized in terms of complexity parameters such as the fractal dimension (FD). It is well known that in any image there are very subtle details that are not easily detectable by the human eye. However, in many cases like medical imaging diagnosis, these details are very important since they might contain some hidden information about the possible existence of certain pathological lesions like tissue degeneration, inflammation, or tumors. Therefore, an automatic method of analysis could be an expedient tool for physicians to give a faultless diagnosis. The fractal analysis is of great importance in relation to a quantitative evaluation of "real-time" elastography, a procedure considered to be operator dependent in the current clinical practice. Mathematical analysis reveals significant discrepancies among normal and pathological image patterns. The main objective of our work is to demonstrate the clinical utility of this procedure on an ultrasound image corresponding to a submandibular diffuse pathology.

Contrast enhanced ultrasonography (CEUS) in the characterization of tumor microcirculation. Validation of the procedure in the animal experimental model.

AIM: The aims of this study are the development of a contrast enhanced ultrasonography (CEUS) protocol for rats' evaluation and the assessment of the potential benefits of CEUS in Walker 256 tumor rats. MATERIAL AND METHOD: In the study were used 36 albino Wistar rats grafted subcutaneously with Walker 256 tumor. The implementation of the ultrasound (US) guided injection technique (30 subjects - group A) was performed between 4 to 8 weeks after implantation. The contrast agent (CA) - Sono Vue (Bracco) - was administered either into the lateral vein of the tail or directly into the heart under US guidance. The US validation, focusing on CEUS (6 subjects - group B) was realized at 4 to 6 weeks after implantation. The US procedures aimed to obtain morphological (2D), vascular (color Doppler and pulsed Doppler) and angiospecific functional data (CEUS). The Vevo 2100 equipment was used for US and Time Intensity Curves (TIC) were analyzed with Sonoliver (TomTec). The tumor specimens which were resected after the last study underwent a pathology exam. RESULTS: A number of 23 successfully CEUS explorations were performed in 17 subjects (11 in group A and 6 in group B). Nineteen rats could not be evaluated (in 8 cases the tumor was not viable; 4 subjects died during CA administration; in 4 cases the administration line could not be obtained). In group B, CEUS was performed in 6 subjects at 4 weeks after implantation and in 5 subjects at 6 weeks. The statistical analysis of the TIC parameters identified significant differences between the Time to Peak, mean Transit Time and Rise Time parameters of the muscles and those of the tumor. CONCLUSIONS: CEUS was easily implemented on the studied tumor model and is adequate for the evaluation of tumor vascularity. US guided intracardiac administration of the CA is an easy and reproducible procedure. If the examination is performed at defined time intervals it detects the alterations within the tumor circulatory bed.

2D ultrasonography and contrast enhanced ultrasound for the evaluation of cavitating mesenteric lymph node syndrome in a patient with refractory celiac disease and enteropathy T cell lymphoma.

BACKGROUND: The cavitating mesenteric lymph node syndrome (CMLNS) is a rare manifestation of celiac disease, with an estimated mortality rate of 50%. Specific infections and malignant lymphoma may complicate its clinical course and contribute to its poor prognosis. Diagnosing the underlying cause of CMLNS can be challenging. This is the first report on contrast enhanced ultrasound (CEUS) findings in enteropathy associated T-cell lymphoma (EATL) complicating CMLNS in a gluten-free compliant patient with persistent symptoms and poor outcome. CASE PRESENTATION: We present the case of a 51-year old Caucasian male patient, diagnosed with celiac disease and CMLNS. Despite his compliance to the gluten-free diet the symptoms persisted and we eventually considered the possible development of malignancy. No mucosal changes suggestive of lymphoma were identified with capsule endoscopy. Low attenuation mesenteric lymphadenopathy, without enlarged small bowel segments were seen on computed tomography. CEUS revealed arterial rim enhancement around the necrotic mesenteric lymph nodes, without venous wash-out. No malignant cells were identified on laparoscopic mesenteric lymph nodes biopsies. The patient died due to fulminant liver failure 14 months later; the histopathological examination revealed CD3/CD30-positive atypical T-cell lymphocytes in the liver, mesenteric tissue, spleen, gastric wall, kidney, lung and bone marrow samples; no malignant cells were present in the small bowel samples. CONCLUSIONS: CEUS findings in EATL complicating CMLNS include arterial rim enhancement of the mesenteric tissue around the cavitating lymph nodes, without venous wash-out. This vascular pattern is not suggestive for neoangiogenesis, as arteriovenous shunts from malignant tissues are responsible for rapid venous wash-out of the contrast agent. CEUS failed to provide a diagnosis in this case.