Different pixel pitch and maximum luminance of medical grade displays may result in different evaluations of digital radiography images.

AIM: To evaluate the effects of display pixel pitch and maximum luminance on intra- and inter-observer reproducibility and observer performance when evaluating chest lesions and bone fractures. MATERIALS AND METHODS: This was a multi-institutional study for a retrospective interpretation of selected digital radiography images. Overall, 82 images were selected by senior radiologists, including 50 cases of chest lesions and 32 cases of bone fractures. These images were displayed at two pixel pitches (0.212 and 0.165 mm size pixels) and two maximum luminance values (250 and 500 cd/m2) and reviewed twice by senior and junior radiologists. All the observers had to indicate the likelihood of the presence of the lesions and to rate the relative confidence of their assessment. Cohen Kappa statistic was computed to estimate the reproducibility in correctly identifying lesions; for multi-reader-multi-case (MRMC) analysis, weighted Jackknife Alternative Free-response Receiver Operating Characteristic (wJAFROC) statistical tools was applied. RESULTS: The intra-radiologist and inter-observer reproducibility values were the highest for the 0.165 mm size pixel at 500 cd/m2 display, for both chest lesions and bone fractures evaluations. As regards chest lesions, observer performances were significantly greater with 0.165 mm size pixel display at 500 cd/m2 than with lower maximum luminance and/or larger pixel pitch displays. Concerning bone fractures, the performance obtained with 0.212 mm size pixel display at 250 cd/m2 was statistically lower than that obtained with 0.165 mm sixe pixel display at 500 cd/m2. CONCLUSION: Our results indicate that an increased maximum luminance level and a decreased pixel pitch of medical-grade display improve the accuracy of detecting both chest lesions and bone fractures.

Acoustic radiation force impulse with shear wave speed quantification of pancreatic masses: A prospective study.

BACKGROUND: Acoustic Radiation Force Impulse (ARFI) is a new ultrasound technique that evaluates mechanical properties of tissues. To evaluate the use of ARFI with shear waves speed quantification for pancreatic masses characterization during the ultrasound examination. METHODS: 123 pancreatic lesions were prospectively evaluated. Median shear waves speeds were compared with Mann-Whitney U test. Two reading methods were applied for the characterization of adenocarcinoma: more than one measurement above the top shear waves speed (SWS) value. Two reading methods were applied to diagnose mucinous lesion: at least 2 (method 1) or 3 (method 2) numerical measurements. Sensitivity, specificity, positive and negative predictive values and accuracy of each reading method were calculated. Forty volunteers were included for normal ARFI values. RESULTS: In the adenocarcinoma group median SWS value was 2.74 m/s. In the volunteers group the median SWS value was 1.17 m/s. Significant difference between SWS median values of adenocarcinoma and normal pancreas was found (P < 0.05). For the diagnosis of pancreatic solid masses if more than one measurement is above the top SWS value of 4.00 m/s results in the study, the diagnosis of ductal adenocarcinoma is highly specific with specificity and PPV of 100%. Good sensitivity (73.3%) and specificity (83.3%) were obtained for the characterization of mucinous cystic lesions. CONCLUSIONS: Acoustic Radiation Force Impulse imaging could help in the non-invasive characterization of solid and cystic lesions of the pancreas during a conventional US examination.

Contrast-Enhanced Ultrasound of Focal Liver Lesions.

OBJECTIVE: The purpose of this article is to discuss the use of contrast-enhanced ultra-sound (CEUS) in focal liver lesions. CONCLUSION: Focal liver lesions are usually detected incidentally during abdominal ultrasound. The injection of microbubble ultrasound contrast agents improves the characterization of focal liver lesions that are indeterminate on conventional ultrasound. The use of CEUS is recommended in official guidelines and suggested as a second diagnostic step after ultrasound detection of indeterminate focal liver lesions to immediately establish the diagnosis, especially for benign liver lesions, such as hemangiomas, avoiding further and more expensive examinations.

Time-to-peak values can estimate hepatic functional reserve in patients undergoing surgical resection: a comparison between perfusion CT and indocyanine green retention test.

OBJECTIVE: To evaluate the potential usefulness of perfusion computed tomography (CT) for the estimation of hepatic functional reserve in patients scheduled for surgical resection and to compare the results with those of the indocyanine green retention test results. METHODS: Thirty-one patients with hepatobiliary malignancies were included. Perfusion CT and indocyanine green retention test were performed on the same day, and their results were compared using Pearson correlation test. RESULTS: A strong correlation was found between perfusion CT time-to-peak values and indocyanine green retention rate at 15 minutes and indocyanine green plasma disappearance rate values (R, 0.789 and -0.790; R, 0.832 and -0.823, respectively; P < 0.0001). CONCLUSIONS: Perfusion CT may be useful for the preoperative noninvasive estimation of hepatic functional reserve for patients undergoing liver resection.

A rare case of incidental pancreatic arteriovenous malformation correctly diagnosed with MDCT.

CONTEXT: Pancreatic arteriovenous malformations are a rare entity that can be incidentally discovered during MDCT examinations. CASE REPORT: We describe a rare case of asymptomatic arteriovenous malformation presenting at MDCT as a hypervascular mass in the pancreatic head. CONCLUSION: Pancreatic arteriovenous malformations are a rare entity, often asymptomatic, that can be correctly diagnosed by MDCT, especially with the use of specific electronic reconstructions.

Virtual analysis of pancreatic cystic lesion fluid content by ultrasound acoustic radiation force impulse quantification.

OBJECTIVES: The purpose of this study was to prospectively evaluate the application of acoustic radiation force impulse (ARFI) imaging implemented with Virtual Touch tissue quantification (Siemens AG, Erlangen, Germany) in the study of pancreatic cystic lesions by using different analysis methods compared with the final diagnosis (pathologic or by magnetic resonance imaging and endoscopic sonographic findings). METHODS: Thirty-eight patients with pancreatic cystic focal lesions (diameter >3 cm and located at a depth of 5.5 cm) were included in the study and underwent conventional sonography. For every patient, 5 measurements in the Virtual Touch tissue quantification region of interest were obtained. To distinguish mucinous (potentially malignant) from serous (mainly benign) cystic lesions, the result XXXX/0 was considered to mean simple liquids (comparable to water), and the accuracy of Virtual Touch tissue quantification in differentiating pancreatic cystic lesions was calculated. To consider a lesion as containing complex fluids (potentially mucinous), two different reading methods were applied: (1) at least 2 numerical values when obtaining 5 measurements; and (2) the prevalence of numerical values irrespective of the number of measurements. The sensitivity, specificity, positive and negative predictive values, and accuracy were calculated for the differential diagnosis between mucinous and nonmucinous cystic lesions. RESULTS: By the first reading method, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy in the group of cystic lesions were 68.8%, 77.3%, 68.8%, 77.3%, and 73.7%, respectively; by the second method, the values were 37.5%, 100%, 100%, 68.8%, and 73.3%. CONCLUSIONS: Acoustic radiation force impulse imaging with Virtual Touch tissue quantification can have a role in the noninvasive characterization of pancreatic cystic lesions during conventional sonographic examinations.

CEUS of the pancreas: Still research or the standard of care.

Contrast-enhanced ultrasonography (CEUS) improves the characterization of pancreatic masses. CEUS is in fact a safe and accurate imaging method to evaluate the vascularity of pancreatic lesions. CEUS should be performed when possible immediately after the ultrasound (US) detection of a pancreatic mass. CEUS is accurate in the characterization of ductal adenocarcinoma. The use of CEUS in studying pancreatic lesions found at US, especially in the same session of ultrasound examination, is therefore recommendable to promote faster diagnosis mainly of pancreatic ductal adenocarcinoma.

Liver volumetry: Is imaging reliable? Personal experience and review of the literature.

The amount of the future liver remnant volume is fundamental for hepato-biliary surgery, representing an important potential risk-factor for the development of post-hepatectomy liver failure. Despite this, there is no uniform consensus about the amount of hepatic parenchyma that can be safely resected, nor about the modality that should be chosen for this evaluation. The pre-operative evaluation of hepatic volume, along with a precise identification of vascular and biliar anatomy and variants, are therefore necessary to reduce surgical complications, especially for extensive resections. Some studies have tried to validate imaging methods [ultrasound, computed tomography (CT), magnetic resonance imaging] for the assessment of liver volume, but there is no clear evidence about the most accurate method for this evaluation. Furthermore, this volumetric evaluation seems to have a certain degree of error, tending to overestimate the actual hepatic volume, therefore some conversion factors, which should give a more reliable evaluation of liver volume, have been proposed. It is widespread among non-radiologists the use of independent software for an off-site volumetric analysis, performed on digital imaging and communications in medicine images with their own personal computer, but very few studies have provided a validation of these methods. Moreover, while the pre-transplantation volumetric assessment is fundamental, it remains unclear whether it should be routinely performed in all patients undergoing liver resection. In this editorial the role of imaging in the estimation of liver volume is discussed, providing a review of the most recent literature and a brief personal series of correlations between liver volumes and resection specimens' weight, in order to assess the precision of the volumetric CT evaluation.

Noninvasive diagnosis of cirrhosis: a review of different imaging modalities.

Progressive hepatic fibrosis can lead to cirrhosis, so its early detection is fundamental. Staging fibrosis is also critical for prognosis and management. The gold standard for these aims is liver biopsy, but it has several drawbacks, as it is invasive, expensive, has poor acceptance, is prone to inter observer variability and sampling errors, has poor repeatability, and has a risk of complications and mortality. Therefore, non-invasive imaging tests have been developed. This review mainly focuses on the role of transient elastography, acoustic radiation force impulse imaging, and magnetic resonance-based methods for the noninvasive diagnosis of cirrhosis.

Contrast enhanced ultrasound with quantitative perfusion analysis for objective characterization of pancreatic ductal adenocarcinoma: A feasibility study.

The aim of this study was to determine whether contrast enhanced ultrasound (CEUS) quantitative perfusion analysis allows an objective characterization of ductal adenocarcinoma (ADK) of the pancreas. Patients with pancreatic ADK underwent CEUS. All examinations were performed on an Acuson S2000 system (Siemens, Erlangen, Germany) after the iv administration of 2.4 mL contrast agent (SonoVue(®), Bracco, Milan, Italy). All lesions were pathologically proved. An operator manually drew different regions of interest within the tumor and the adjacent parenchyma to allow the quantitative perfusion analysis. The mean values of peak of enhancement, time to peak and ascending curve were calculated and compared using the Student's t test. The quantitative perfusion analysis was possible in all lesions. The mean values of the peak of enhancement, time to peak and ascending curve were 17.19%, 7.97 s and 159.52% s within the tumor and 33.57%, 8.89 s and 355.29% s within the adjacent parenchyma. The peak of enhancement and the ascending curve values were significantly different within the tumor and the adjacent parenchyma. Thus, CEUS allows the quantitative perfusion analysis of pancreatic ductal adenocarcinoma.

Elastography of the pancreas.

Elastography has recently been presented in clinical studies as a new technique applied to US imaging. The challenge of this new technique is to distinguish different tissues on the basis of their specific consistency. Since malignant tumors tend to be harder than benign lesions and parenchyma, this new approach could result clinically relevant. Initial clinical experiences in US elastography have been promising in differentiating breast, thyroid and prostate nodules. Pancreatic applications of US elastography are relatively recent and under validation with several studies so far published in literature.

Autoimmune pancreatitis: Multimodality non-invasive imaging diagnosis.

Autoimmune pancreatitis (AIP) is characterized by obstructive jaundice, a dramatic clinical response to steroids and pathologically by a lymphoplasmacytic infiltrate, with or without a pancreatic mass. Type 1 AIP is the pancreatic manifestation of an IgG4-related systemic disease and is characterized by elevated IgG4 serum levels, infiltration of IgG4-positive plasma cells and extrapancreatic lesions. Type 2 AIP usually has none or very few IgG4-positive plasma cells, no serum IgG4 elevation and appears to be a pancreas-specific disorder without extrapancreatic involvement. AIP is diagnosed in approximately 2%-6% of patients that undergo pancreatic resection for suspected pancreatic cancer. There are three patterns of autoimmune pancreatitis: diffuse disease is the most common type, with a diffuse, "sausage-like" pancreatic enlargement with sharp margins and loss of the lobular contours; focal disease is less common and manifests as a focal mass, often within the pancreatic head, mimicking a pancreatic malignancy. Multifocal involvement can also occur. In this paper we describe the features of AIP at ultrasonography, computed tomography, magnetic resonance and positron emission tomography/computed tomography imaging, focusing on diagnosis and differential diagnosis with pancreatic ductal adenocarcinoma. It is of utmost importance to make an early correct differential diagnosis between these two diseases in order to identify the optimal therapeutic strategy and to avoid unnecessary laparotomy or pancreatic resection in AIP patients. Non-invasive imaging plays also an important role in therapy monitoring, in follow-up and in early identification of disease recurrence.

Contrast-enhanced ultrasound of pancreatic tumours.

Indication/purpose: To review contrast-enhanced ultrasound features of the most common pancreatic tumours. Methods: Contrast-enhanced ultrasound (CEUS) can provide distinctive features of pancreatic tumours that are reported in the present paper, providing radiologic-pathological correlations and clarifying the main differential diagnosis. Conclusion: Contrast-enhanced ultrasound plays a well-established role in the evaluation of pancreatic tumours. When possible, CEUS should be always performed after the initial US diagnosis, in order to improve the accuracy of the first line examination.

Acoustic radiation force impulse of the liver.

Acoustic radiation force impulse (ARFI) imaging is a new and promising ultrasound-based diagnostic technique that, evaluating the wave propagation speed, allows the assessment of the tissue stiffness. ARFI is implemented in the ultrasound scanner. By short-duration acoustic radiation forces (less than 1 ms), localized displacements are generated in a selected region of interest not requiring any external compression so reducing the operator dependency. The generated wave scan provides qualitative or quantitative (wave velocity values) responses. Several non-invasive methods for assessing the staging of fibrosis are used, in order to avoid liver biopsy. Liver function tests and transient elastography are non-invasive, sensitive and accurate tools for the assessment of liver fibrosis and for the discrimination between cirrhotic and non-cirrhotic liver. Many published studies analyse ARFI performance and feasibility in studying diffuse liver diseases and compare them to other diagnostic imaging modalities such as conventional ultrasonography and transient elastography. Solid focal liver lesions, both benign and malignant, are common findings during abdominal examinations. The accurate characterization and differential diagnosis are important aims of all the imaging modalities available today. Only few papers describe the application of ARFI technology in the study of solid focal liver lesions, with different results. In the present study, the existing literature, to the best of our knowledge, about ARFI application on diffuse and focal liver pathology has been evaluated and results and statistical analyses have been compared, bringing to the conclusion that ARFI can be used in the study of the liver with similar accuracy as transient elastography in diagnosing significant fibrosis or cirrhosis and has got some advantages in respect to transient elastography since it does not require separate equipment, better displays anatomical structures and measurements can be successfully carried out almost in every patient.