Liver resection and local ablation of breast cancer liver metastases--a systematic review.

AIM: To analyze surgical treatment of breast cancer liver metastases (BCLM) regarding selection criteria, outcome and prognostic parameters. METHODS: We searched Embase and Medline for all studies published 1999-2010. RESULTS: Resection was associated with a median survival (MOS) of 20-67 months and 5-year survival of 21-61%. Local ablation also had a favorable outcome; MOS was 30-60 months and 5-year survival 27-41%. Regarding selection, no specific limits regarding the number and size of BCLM can be given. Features of the primary breast cancer (BC) were not significant for the prognosis. Microscopically radical (R0) resection is a positive prognostic factor, while the effects of disease interval, hormone receptor status and response to preoperative chemotherapy were divergent. The presence of EHD had a negative effect on survival in some studies, but failed to have so in other studies. CONCLUSIONS: Surgical therapy may benefit a subset of patients with BCLM. Resection may be indicated, if an RO-resection can be done with a low risk of mortality. Liver resection in the presence of extrahepatic disease remains controversial, while patients with BCLM and bone metastases could possibly be managed differently than other EHD.

Microwave ablation of liver metastases guided by contrast-enhanced ultrasound: experience with 125 metastases in 39 patients.

PURPOSE: The aim of our study was to evaluate the efficacy of microwave (MW) ablation of liver metastases guided by B-mode ultrasound (US) and contrast-enhanced US (CEUS). MATERIALS AND METHODS: 39 patients (17 women and 22 men) with a total of 125 liver metastases were treated with percutaneous or intraoperative CEUS-guided MW ablation. The primary tumor was colorectal cancer (n = 31), breast cancer (n = 6), carcinoid tumor (n = 1), and gastrointestinal stromal tumor (GIST) (n = 1). The median number of metastases ablated in the 45 treatment sessions was 2 (range 1 - 11). The median size (maximum diameter) of the 125 metastases was 1.5 cm (range, 0.6 - 4.0 cm). Nineteen (15 %) of the 125 metastases were bigger than 2 cm. Metastases smaller than 2 cm were treated with a single needle, metastases bigger than 2 cm were treated with 2 or 3 parallel needles. RESULTS: The 45 MW ablation sessions were performed percutaneously (n = 30), during laparotomy (n = 3), or during laparotomy combined with liver resection (n = 12). The 39 patients were followed up for at least 4 months with a median duration of 11 months (range, 4 - 20 months). The technical success rate was 100 %. The clinical effectiveness was 100 % with complete coverage of the metastasis by the avascular coagulation zone evaluated on immediate post-ablation CEUS. Local tumor progression (local recurrence) was seen in 12 (9.6 %) of the 125 treated metastases, and affected 10 (26 %) of the 39 patients. One major complication was observed in the form of a liver abscess that easily resolved after percutaneous drainage. Four minor complications were observed: Three cases of pain located at the puncture site and one case of ascites. CEUS was valuable in all phases of ablation including pre-ablation staging and procedure planning, placement of MW needles in the tumor, immediate post-ablation control of coagulation size, and finally in the long term follow-up regime. CONCLUSION: CEUS-guided MW ablation of liver metastases is an efficient and safe ablation technique with several advantages compared to other ablation modalities.

Urinary bladder volume measurements: comparison of three ultrasound calculation methods.

OBJECTIVE: To assess the precision of three different automatic calculation methods in real-time bladder volume measurement. MATERIAL AND METHODS: Bladders from 34 medical staff volunteers were examined. Two examinations of each subject were performed independently by 2 examiners using 2 identical ultrasound scanners with no delay between the examinations. Three different automatic calculation algorithms, available as software in the ultrasound scanner, were applied on the frozen ultrasound pictures. After registration of the voided volume with an uroflowmeter, the subjects were scanned again in order to assure complete emptying. RESULTS: Voided volumes ranged from 45 ml to 508 ml. The precision of each method was equal but the LWH method measured significantly lower values than the ELLIPSOID and AREA method. Errors in the range of -56.1% to +58.8% for all volumes and methods were found. Data for voided volumes greater than 150 ml (n = 29) were investigated separately, but no significant improvement in accuracy for any of the methods was found. CONCLUSIONS: Ultrasound bladder volume calculation is an easy method for estimation of bladder volume. The prolate ellipsoid method (LWH) is recommended as the standard calculation method because it is fast and easy. Unacceptable large measure errors are found and too rigid conclusions based on ultrasound measurements of bladder volume should be avoided.

Chronic idiopathic anal pain: analysis of ultrasonography, pathology, and treatment.

PURPOSE: This study was undertaken to analyze whether intra-anal ultrasound examination, anorectal physiologic evaluation, and histopathologic examination in patients with chronic idiopathic anal pain presented any common features and whether the results of different treatment modalities correlated with these findings. METHODS: Eighteen patients who met the criteria for chronic idiopathic anal pain were studied. All had an intra-anal ultrasound examination and a complete anorectal physiologic evaluation. In a selected group of patients, ultrasound-guided biopsy samples were taken from pathological areas in the internal and external sphincter. Treatment consisted of analgesics only in four patients, 0.2 percent nitroglycerin ointment in four, and ultrasound injection of botulin (botulinum toxin, Botox) into the intersphincteric space in nine. Two patients, including one who was previously treated with botulin, ultimately had a colostomy. RESULTS: Four patients were managed satisfactorily on analgesic treatment under the guidance of the hospital's pain clinic. Nitroglycerin ointment resulted in temporary pain relief in one of four patients. Injection of botulin resulted in a permanent improvement in four patients, a temporary improvement in one patient, and no effect in four patients. Two patients had a colostomy, resulting in complete pain relief. The effect or lack of effect of nitroglycerin ointment and botulin was not related to changes in anal pressure. CONCLUSION: Chronic idiopathic anal pain is a condition of unknown origin for which no proven therapy exists. As in other syndromes based on muscular dystonia, some patients may benefit from injection of botulin.

Impact of intraoperative ultrasonography on surgical treatment of liver tumours.

PURPOSE: The aim of this study was to evaluate the impact of intraoperative ultrasonography (IOUS) on surgical decision-making in patients with liver tumours. MATERIAL AND METHODS: IOUS of the liver was performed in 116 patients undergoing surgery for liver tumours. The patients were evaluated preoperatively by ultrasonography, CT and in some cases, by ERCP and scintigraphy. IOUS findings were compared with the results of preoperative imaging and surgical findings. RESULTS: The surgical procedures were altered in 50 cases (43%), extended in 19 cases (16%) and reduced in 8 cases (7%). Twenty-three patients (20%) were found inoperable. Intraoperative evaluation caused surgical modification by IOUS in 13 patients (11%), by surgical findings in 14 patients (12%) and by a combination of both in 23 patients (20%). CONCLUSION: IOUS is a precise diagnostic method for staging the operability of liver tumours. Unnecessary surgical procedures can be avoided. In total, IOUS altered the preoperative plan in one-third of our patients and is therefore recommended as a routine procedure in connection with major liver surgery.

Ultrasonic measurement of the anterior translation in the shoulder joint.

A new method for measuring the anterior translation in the shoulder joint by dynamic ultrasound was evaluated. We placed a 3.5-MHz transducer on the shoulder anteriorly. By using 3 bony landmarks, we then measured the anterior translation of the humeral head with a force of 90 N applied posteriorly. We performed such measurements in 20 subjects with healthy shoulders and in 20 patients with unilateral shoulder instability. There was a mean translation of 1.9 mm in healthy shoulders and 4.9 mm in unstable shoulders (P < .01). The mean difference between the 2 sides in subjects with normal shoulders was 0.7 mm, whereas the mean difference in patients with instability was 2.8 mm (P < .01). The normal shoulders were examined by 2 examiners to determine the degree to which different examiners' measurements might vary. Although one examiner recorded higher values than the other, the new method seems suitable for measuring increased laxity in unstable shoulders.

Perioperative Doppler ultrasonography: renal detection of renal graft perfusion.

Irreversible damage of renal transplants may be prevented if insufficient graft perfusion can be detected perioperatively. Colour and spectral Doppler ultrasonography were performed in 30 consecutive renal transplants. The perfusion of the graft and the Resistive Index (RI) were evaluated perioperatively (perioperatively and less than 15 min postoperatively) and 24 h after the operation in all patients. In four cases (13.3%) RI > 0.9 was detected and immediate surgical correction of the cause led to a normalization (RI < 0.8) in all four cases. A RI < 0.9 required no intervention in 26 cases (86.7%). All renal grafts in this series were functioning 1 month postoperatively. In a comparative group, 30 consecutive transplants carried out at our institution without perioperative Doppler ultrasonography evaluation, a loss of four renal grafts perioperatively was recorded retrospectively. We conclude that perioperative ultrasonography Doppler evaluation may provide an easy applicable and reliable method for early detection of insufficient renal graft perfusion, allowing surgical correction before irreversible damage of the graft occurs. RI > 0.9 is pathological. A continuation of the study is required to clarify the long-term value of perioperative Doppler ultrasonography graft monitoring.

Doppler ultrasound assessment of TIPS patency and function--the need for echo enhancers.

PURPOSE: The aim of this study was to illustrate the versatility of an i.v. administered echo enhancer for Doppler US assessment of TIPS patency and function. MATERIAL AND METHODS: A total of 22 Doppler US evaluations of TIPS patency and function were performed in 5 patients with alcoholic cirrhosis and recurrent oesophageal bleeding who had been treated with TIPS. TIPS patency was evaluated by means of colour or power Doppler US. The volume flow (VF) was assessed in the TIPS and in the portal vein by spectral Doppler. The ratio of the VF in the TIPS to the VF in the portal vein (T/P ratio) was used to express the functional status of the TIPS. If Doppler signals were inconclusive or absent, echo-enhanced US was performed. RESULTS: In 22 follow-up Doppler US examinations, echo-enhanced Doppler US was required in 7 cases (29%). The Doppler enhancement persisted in the range of 3-5 min. No adverse effects were observed. An apparently normal TIPS function reflected a T/P ratio in the range of 0.44-1.10, median 0.78 +/- 0.20 (2SD). CONCLUSION: The i.v. administration of echo enhancers would seem to be indicated in the assessment of the TIPS function if conventional Doppler US fails to prove normal TIPS patency and function. The T/P ratio may be a convenient monitoring parameter for reflecting the TIPS function.

[Transjugular intrahepatic portosystemic shunt. Treatment of patients with recurrent bleeding from esophageal varices]. / Transjugular intrahepatisk portosystemisk shunt. Behandling af patienter med recidiverende esophagusvariceblødning.

We report the results of transjugular intrahepatic portosystemic shunt (TIPS) procedure in six patients with liver cirrhosis and recurrent bleeding or acute intractable bleeding from oesophageal varices in spite of multiple sessions of sclerotherapy. Median follow-up was 15 months (range 1-24 months). The procedure was technically successful in all patients without procedure-related morbidity or mortality. Four of the procedures were performed electively and two as an emergency procedure. The portosystemic pressure gradient decreased to below 12 mmHg following TIPS implantation and the shunt bloodflow was one quarter to three-quarters of the portal bloodflow determined by Doppler ultrasound. Recurrent bleeding occurred in one patient but was amenable to endoscopic sclerotherapy. In this patient the shunt had developed a stenosis that was treated by balloondilatation and insertion of an additional stent six months following the initial procedure, and no further bleeding occurred. The remaining five patients had no rebleeding episodes. Repeated Doppler examinations in the followup period demonstrated patency of all shunts. None of the patients developed portosystemic encephalopathy. One patient died of cerebral haemorrhage, unrelated to TIPS, 16 months following implantation. Another patient died 14 months following TIPS due to acute mesenteric occlusion and septicaemia. We conclude that TIPS is feasible and effective in selected patients with liver cirrhosis and persistent or recurrent variceal bleeding following repeated endoscopic therapy.

Intramuscular myxoma and fibrous dysplasia of bone--Mazabraud's syndrome. A case report.

We present a case of Mazabraud's syndrome, a rare benign disease, with multiple intramuscular myxomas of the thoracic wall associated with fibrous dysplasia of bone. CT, MR imaging and ultrasonography (US) of the thorax showed 2 well circumscribed homogeneous intramuscular tumors. A US-guided needle biopsy with a large-core needle (2.0 mm) and a fine needle (0.8 mm) showed that the tumors were intramuscular myxomas with no sign of malignancy. 99mTc bone scintigraphy showed a markedly increased uptake in the right lower skull, and multiple smaller foci. CT of the skull revealed a right-sided unilateral bone thickening of the orbit and the ethmoidal cells, and right-sided exophthalmia. This case history suggests that patients with multiple intramuscular myxomas should be preoperatively examined for osseous lesions. A postoperative follow-up should also be performed to detect other soft-tissue myxomas not as yet clinically detectable, or rare osseous complications.

[Hepatic metastases disclosed by laparoscopy and echographic laparoscopy. Impact of ultrasound-guided biopsy]. / Métastases hépatiques découvertes par laparpscopie et écho-laparoscopie. Impact de la biopsie échoguidée.

UNLABELLED: The aim of this prospective study was to study the impact of biopsies of liver metastases guided by laparoscopic ultrasound (LUS) and to evaluate various biopsy techniques. MATERIAL AND METHODS: Laparoscopy with LUS was performed on 18 consecutive patients with liver metastases considered to be surgically curable. Any new liver lesion which could lead to a therapeutic modification was biopsied, with a forceps or guided by LUS using four different techniques. RESULTS: Of 17 patients successfully examined, a biopsy was indicated in 12 cases (71%), extension of the surgical procedure was decided in four cases (24%), and laparotomy was avoided in six cases (35%). The preoperative staging was correct in 15 stages (88%) and incorrect in two cases (12%). The positioning of the puncture needle in the axis of the scanning plane by "free hand" or in association with an abdominal transducer was effective, without complications. CONCLUSION: Any liver lesion discovered by LUS which could lead to a modification or abstention of surgery should be biopsied, with LUS-guidance in the case of deep lesions. However, an optimal and universal guiding system for LUS-probes, has not yet been developed.

Interventional ultrasound.

Interventional ultrasound, i.e., US-guided interventions, are diagnostic or therapeutic minimally invasive procedures guided by real-time ultrasound imaging, preferably using attachable needle steering devices. Guided fine- and coarse-needle biopsies of US-detectable abnormalities provide a firm basis for diagnosis and therapy. Multiple US-guided drainage and catheterization procedures such as nephrostomy, pleuracentesis, cholecystostomy, abscess drainage and central venous catheterization, etc., are rapid and safe alternatives to conventional drainage methods and open surgery. Devices and methods for US-guided minimally invasive focal tissue ablation are rapidly developing. Focal treatment of malignant tumours in the liver and prostate, using a variety of US-guided methods, are investigated. Complications of interventional ultrasound are reportedly low with a 0.19% overall complication rate and a 0.04% mortality rate. It is concluded that ultrasound provides a safe and cost-effective dynamic imaging modality for guidance of the increasing range of diagnostic and therapeutic interventional procedures.

[Ultrasonic angiography: principles and clinical use]. / Ultralydangiografi: princip og kliniske anvendelser.

A new technique for detecting blood flow called Colour Doppler Energy (CDE), Power Doppler or Ultrasound Angio, is based on the integrated power spectrum of the standard Doppler signal used for Colour Flow Mapping (CFM). CDE is independent of the insonation angle, has no aliasing artefacts and improves the sensitivity with respect to detection of the presence or absence of flow compared to CFM. However, CDE provides no directional or quantitative information about the flow. CDE is superior to CFM in detection of low velocity flow, perfusion in small vessels, flow in torsioned vessels and flow in multiple vessels in the same image plane. The clinical applications are reviewed. Complicated stenosis, renal perfusion, penile Doppler and scanning of the vessels of the extremities are examples where CDE improves sensitivity in detecting flow compared to CFM.

Percutaneous gastrostomy guided by ultrasound and fluoroscopy.

Percutaneous gastrostomy, utilizing a dedicated catheterization kit, with a combination of ultrasonographic (US) and fluoroscopic guidance, was carried out in 27 patients. The main indication for gastrostomy was the need for nutritional support in malignant esophageal stricture. After distending the stomach with water via a nasogastric tube, the gastric antrum was punctured under US guidance and a guide wire was inserted, followed by fluoroscopically guided tract dilatation and insertion of a 2.5-mm Cope-loop catheter. In all patients but one (96%) the procedure was successfully completed in one or 2 attempts. Two complications occurred: one case of a small subcutaneous abscess near the puncture site, and one late incident of dislodgement of a catheter without string-loop fixation, which had been inserted at a catheter exchange after 6 weeks. Percutaneous gastrostomy guided by US and fluoroscopy is a safe and efficacious alternative to endoscopic and surgical gastrostomy.