Ultrasound imaging classifications of thyroid nodules for malignancy risk stratification and clinical management: state of the art.

Assessing the risk of malignancy in the thyroid with ultrasound (US) is crucial in patients with nodules, as it can aid in selecting those who should have a fine-needle aspiration (FNA) biopsy performed. Many studies have examined whether the US characteristics of thyroid nodules are useful indicators of histological malignancy. Overall, these investigations have identified a few US features that are significantly more frequent in malignant thyroid nodules which can be coalesced into a defining set to be used as an indicator of a higher risk of malignancy. Despite these efforts, none of these classifications have been widely adopted worldwide, and there are still conflicting recommendations from different institutions. Understanding the role and appropriate utilization of these systems could facilitate the effective interpretation and communication of thyroid US findings among referring physicians and radiologists. In this comprehensive review, we outline the major US classification systems of thyroid nodules published in the last few years.

Cooled tip radiofrequency ablation of benign thyroid nodules: preliminary experience with two different devices.

BACKGROUND: Thyroid nodules are very common in general population. Even if benign, they may require a treatment in case of symptoms or cosmetic concerns. In the last years, minimally invasive treatments alternative to surgery have been developed, in particular ultrasound (US) guided radiofrequency ablation (RFA). METHODS: Twenty-four patients (9 males; 15 females; mean age 57.9 years) were treated and divided in two groups (A and B) according to the RFA needle used (18 gauge needle, AMICA; 17 gauge needle, COVIDIEN). Nodules and patients characteristics, together with procedural data were registered pre-treatment and at 1-month follow-up. US visibility of the needle, volume of the nodules, symptoms and cosmetic concerns, complications were registered. RESULTS: Visibility of the needle was not significantly different in the two groups (P=0.0787). At 1 month the mean volume of the nodules dropped from 37.1 to 25 mL in group A and from 23.2 to 15.4 mL in group B; shrinkage rate (36.9% and 39.5%, respectively) was not significantly different (P=0.3137). Symptoms decreased from 3.1 to 1.4 in group A and from 4 to 1.6 in group B: no significant differences in reductions were observed (P=0.3305). Cosmetic score decreased from 3.7 to 3.4 in group A and from 3.9 to 3.6 in group B: no significant differences in reductions were observed (P=0.96). Total complication rate (18.2% in group A vs. 23.1% in group B) did not showed significant differences (P=0.5049). CONCLUSIONS: The two systems used in our study resulted equivalent in terms of US needle visibility, efficacy, symptom/cosmetic relief, safety. More patients and a longer follow-up are necessary to confirm our results.

Use of the ultrasound-based total malignancy score in the management of thyroid nodules.

PURPOSE: The purpose of this study was to validate the role of the total malignancy score (TMS) in identifying thyroid nodules suspicious for malignancy through the sum of their ultrasound features. METHODS: The local ethical committee approved this prospective observational study. We examined 231 nodules in 231 consecutive patients (164 females and 67 males; age range, 20 to 87 years; median age, 59 years; interquartile range, 48 to 70 years) who underwent ultrasound followed by fine-needle aspiration cytology (FNAC). The nodules were further classified using the TMS, which considers ultrasound features (number, echogenicity, structure, halo, margins, Doppler signal, calcifications, and growth), and the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC), which considers cytological features. Patients with non-negative nodules (TBSRTC categories III to VI) underwent histological analysis, repeated FNAC, or 2 years of regular ultrasound follow-up. The associations between the final diagnosis, each of the ultrasound features, and the TMS were estimated using the chi-square test, the Mann-Whitney U test, and multivariate logistic regression. A receiver operating characteristic (ROC) curve was used to evaluate the diagnostic accuracy of the TMS. RESULTS: On ultrasound, 47% of the nodules (108 of 231) had a TMS >3, 18% (42 of 231) had a TMS of 3, and 35% (81 of 231) had a TMS >3. The FNAC results of 85% of the nodules (196 of 231) were benign, while 15% (35 of 231) had non-negative results. Hypoechogenicity, solid structure, the presence of microcalcifications, and the number of nodules were independent predictors of the final diagnosis, and the diagnostic accuracy of the TMS was good (area under the ROC curve, 0.82). CONCLUSION: The TMS system is simple to use, reliable, easily reproducible, and closely reflects malignancy risk. Based on our results, FNAC could be limited to nodules with a TMS ≥3 without missing any cases of carcinoma.

A multiparametric analysis combining DCE-MRI- and IVIM -derived parameters to improve differentiation of parotid tumors: a pilot study.

AIM: To evaluate dynamic contrast-enhanced (DCE)-MRI and diffusion weighted (DW)-MRI diagnostic value to differentiate Warthin tumors (WT) by pleomorphic adenomas (PA). MATERIALS & METHODS: Seven WT and seven PA were examined. DCE- and  DW-MRI parameters were extracted from volumes of interest; volume of interest-based averages and standard deviations were calculated. Statistical analysis included: linear discriminant analysis, receiver operating characteristic curves, sensitivity and specificity. RESULTS: No single feature was able to differentiate WT by PA (p > 0.05); linear discriminant analysis analysis showed that a combination of all features or combinations of feature pairs (namely: Ktrans(std) & f(std), Ktrans(std) & D(std), kep(std) & D(std), MRE(av) & TTP(av)) might achieve sensitivity (SENS), specificity (SPEC) = 100%, with a slight reduction after cross-validation analysis (SENS = 0.875; SPEC = 1). CONCLUSION: Although preliminary and not conclusive, our results suggest that differentiation between WT and PA is possible through a multiparametric approach based on combination of DCE- and DW-MRI parameters.

Clinical and instrumental assessment of herniated discs after nucleoplasty: a preliminary study.

BACKGROUND AND AIM: The therapy for low back pain boasts different approaches; one of these is nucleoplasty. We wanted to assess the effectiveness of nucleoplasty both by clinical response both by MR imaging evaluation, including even extrusions larger than one third of the spinal canal. METHODS: Fifty-seven patients were treated with nucleoplasty in our hospital, 11 of these patients accepted both clinical and MRI evaluation after six months from treatment. The clinical evaluation was performed with Visual Analogue Scale (VAS) of pain, scored before and after the procedure. MRI evaluation consisted of analysing some imaging parameters of disc protrusions before and after the treatment. RESULTS: In 10 out of 11 (91%) patients, VAS was reduced and only 1 out of 11 (9%) had the same pain after procedure. The mean of decrease of VAS score was 64%. In our population 8/11 (72%) patients had a herniation larger than 1/3 of the sagittal diameter of spinal canal and 100% of them had an improvement with a mean VAS reduction value of 75%. With MRI evaluation, the mean percentage of expulsion before and after treatment was respectively 40% and 34%. The expulsion decreased in 7/13 discs, remained equal in 4/13, and increased in 2/13 discs. Among the 9 larger protrusions, 3 didn't change, 6 reduced with a decrease mean value of 13%. Other MRI parameters didn't change significantly. CONCLUSIONS: Our preliminary experience supports the success of coblation on pain relief, aiming to show progressively that this treatment is suitable even in case of great extrusions, which are generally treated only with surgical approach. It's not clear the usefulness of MRI control yet, even if in most of cases we could have found a certain reduction of expulsion degree.

Intravoxel Incoherent Motion (IVIM) Diffusion Weighted Imaging (DWI) in the Periferic Prostate Cancer Detection and Stratification.

The aim of this study was to compare the Intravoxel Incoherent Motion (IVIM) parameters between healthy Peripheral Zone (PZ), Benign Prostatic Hyperplasia (BPH) and Prostate Cancer (PCa) and compare them to assess whether there was correlation with Gleason Score (GS) grading system. Thirty-one patients with suspect of PCa underwent 1.5T Multi-Parametric Magnetic Resonance Imaging (MP-MRI) with endorectal coil with a protocol including T2WI, DWI using 10 b values (0, 10, 20, 30, 50, 80, 100, 200, 400, 1000 s/mm2) and DCE. Monoexponential and IVIM model fits were used to calculate both apparent diffusion coefficient (ADC) and the following IVIM parameters: molecular diffusion coefficient (D), perfusion-related diffusion coefficient (D*) and perfusion fraction (f). The ADC and D values were significantly lower in the PCa (0.70 ± 0.16 × 10-3 mm2/s and 0.88 ± 0.31 × 10-3 mm2/s) compared to those found in the PZ (1.22 ± 0.20 × 10-3 mm2/s and 1.78 ± 0.34 × 10-3 mm2/s) and in the BPH (1.53 ± 0.23 × 10-3 mm2/s and 1.11 ± 0.28 × 10-3 mm2/s). The D* parameter was significantly increased in the PCa (5.35 ± 5.12 × 10-3 mm2/s) compare to the healthy PZ (3.02 ± 2.86 × 10-3 mm2/s), instead there was not significantly difference in the PCa compare to the BPH (5.61 ± 6.77 × 10-3 mm2/s). The f was statistically lower in the PCa (9.01 ± 5.20%) compared to PZ (10.57 ± 9.30%), but not significantly different between PCa and BPH (9.29 ± 7.29%). The specificity, sensitivity and accuracy of T2WI associated with DWI and IVIM were higher (100, 98 and 99%, respectively) than for T2WI/DWI and IVIM alone (89, 92 and 90%, respectively). Only for ADC was found a statistical difference between low- and intermediate-/high-grade tumors. Adding IVIM to the MP-MRI could increase the diagnostic performance to detect clinically relevant PCa. ADC values have been found to have a rule to discriminate PCa reliably from normal areas and differed significantly in low- and intermediate-/high-grade PCa. In contrast, IVIM parameters were unable to distinguish between the different GS.

Microwave ablation for thyroid nodules: a new string to the bow for percutaneous treatments?

BACKGROUND: Thyroid nodules are a fairly common finding in general population and, even if most of them are benign, a treatment can be however necessary. In the last years, non surgical minimally invasive techniques have been developed to treat this pathology, starting from percutaneous ethanol injection (PEI), to laser ablation (LA), radiofrequency ablation (RFA) and, most recently, microwave ablation (MWA). METHODS: We reviewed all medical literature searching in pubmed.gov the terms "microwave" & "thyroid". We found three original studies concerning MWA treatment, for a total of 263 patients (mean age 51.0 years; range, 15-80 years; male to female ratio 2.55) and 522 nodules. RESULTS: A total of 522 nodules (338 solid, 22 cystic, 162 mixed) in 263 patients were treated. Studies have shown a mean reduction in volume of thyroid nodules ranging from 45.9% to 65%. No study reported a significant and definitive change in laboratory parameters, except for one case (Heck et al.). No studies have reported major complications after procedure. CONCLUSIONS: MWA is a new, promising technique among the minimally invasive treatments of thyroid nodules. Actually, the larger diameter of MW antenna seems to be the major limiting factor in the use of this technique. More studies are necessary to evaluate feasibility, safety and efficacy of the procedure.

Myocardial Fatty Foci in Adult Patients with Tuberous Sclerosis Complex: Association with Gene Mutation and Multiorgan Involvement.

PURPOSE: To estimate the association between myocardial fatty foci (MFF) on chest computed tomographic (CT) images and type of gene mutation or multiorgan involvement in patients with tuberous sclerosis complex (TSC). MATERIALS AND METHODS: This retrospective case-control study was approved by the ethics committee, which waived the need for patient consent. Forty-eight patients with definite TSC (41 women; mean age, 35 years ± 11 [standard deviation]) and 96 age- and sex-matched patients without TSC who had undergone chest CT were evaluated. Two blinded readers independently scored MFF as low-attenuation areas within the myocardium. Patient history, gene mutation, and multiorgan involvement were obtained from clinical records. Cohen κ, Mann-Whitney U, χ(2) or Fisher exact, Kruskal-Wallis, and Spearman statistics were calculated. RESULTS: One or more MFF was detected in 50% (24 of 48) of patients with TSC; however, no MFF was detected in control patients (P < .001). MFFs were oval (62%, 15 of 24) or linear (38%, nine of 24) and involved the left ventricle in 13 patients and both ventricles in 24 patients (mostly the apical or midleft ventricle); median size was 127 mm(2). After four patients with TSC and unknown mutational status (two with MFF) were excluded, MFF was detected in 53% (10 of 19) of patients with TSC1 mutation, 65% (11 of 17) of patients with TSC2 mutation, and 12% (one of eight) of patients with TSC but without an identified mutation (P = .044). MFF presence was associated with brain (P = .011) and multiorgan (P = .008) involvement. The number of MFF per patient correlated with the degree of multiorgan involvement (P = .014). With MFF considered predictive of TSC, 50% (24of 48) sensitivity, 100% (96 of 96) specificity, 100% (24 of 24) positive predictive value, and 80% (96 of 120) negative predictive value were obtained. CONCLUSION: MFF was highly specific for TSC. MFF presence was associated with TSC gene mutations and with brain or multiorgan involvement; their number per patient was correlated with the degree of multiorgan involvement.

Management of thyroid follicular proliferation: an ultrasound-based malignancy score to opt for surgical or conservative treatment.

This study was conducted to evaluate whether ultrasound characteristics of thyroid nodules with a known cytologic diagnosis of "follicular pattern" (indicative of follicular hyperplasia, follicular adenoma or follicular carcinoma) can be used to define a nodule malignancy score to limit surgery to selected, higher-risk cases. In pre-operative ultrasound results of patients diagnosed with a "follicular pattern" on cytology who subsequently underwent surgery, each nodule feature was given a score from 0 (most likely benign) to 2 (most likely malignant), resulting in a total score ranging from 0 to 11. The total nodule score (total malignancy score) was then compared with the definitive histologic diagnosis. According to our results, surgery is advisable in patients with score ≥4 (79% of carcinomas), ultrasound follow-up seems to be appropriate for patients with a score of 3 (21% of carcinomas) and no action is recommended for patients with score <3 (only benign nodules).

Role of magnetic resonance imaging in evaluation of the activity of perianal Crohn's disease.

AIM: To evaluate the diagnostic ability of contrast-enhanced Magnetic Resonance Imaging (MRI) in assessment of the activity of perianal fistulas in Crohn's disease (CD) patients, compared to clinical data. MATERIALS AND METHODS: Fifty CD patients (25 men; mean[SD] age: 40.4[12.6] years) with known or suspected perianal fistulas underwent perianal space MRI. Radiological activity of disease was measured as the percentage increase (PI) of ROI values of fistulas in relation to ROI values of healthy local fat, after contrast administration. Clinical activity of disease was defined according to Perianal Disease Activity Index (PDAI) and Fistula Drainage Assessment (FDA). RESULTS: Forty-two patients presented perianal disease at MRI (55 fistulas identified). An association between both fistula's PI and PDAI (Pearson's coefficient 0.512, p<0.0001) and between PI and FDA (p=0.003) was demonstrated. Areas under ROC curves of PI values in relation to PDAI and FDA were respectively 0.876 [95%CI=(0.743-1.00), p<0.001] and 0.784 [95%CI=(0.588-0.980), p=0.003]. A cut-off value of PI, calculated on these preliminary data, correctly classified more than 90% of fistulas. CONCLUSIONS: Contrast-enhanced MRI with PI calculation offered practical information about activity of perianal fistulas and might be helpful in providing a comprehensive evaluation of CD perianal disease.

Magnetic resonance imaging of renal involvement in genetically studied patients with tuberous sclerosis complex.

PURPOSE: To evaluate renal involvement in tuberous sclerosis complex (TSC). MATERIALS AND METHODS: A series of 24 TSC patients (19 with genetically demonstrated disease), underwent abdominal 1.0-T MR imaging with axial/coronal T1- and T2-weighted scans, with/without fat saturation. We looked for angiomyolipomas (AMLs) and cysts in 47 kidneys of 24 patients. We evaluated the percentage of parenchymal involvement by manual contouring on the coronal scans in 39 kidneys of 20 patients. RESULTS: We detected AMLs in 15/24 (63%) patients and in 27/47 (57%) kidneys, cysts in 14/24 (58%) and in 26/47 (55%); respectively. AMLs were found in 2/4 TSC1 and in 11/15 TSC2 patients, cysts were found in 2/4 TSC1 and in 9/15 TSC2 patients. The global renal involvement ranged from 0 to 32% (median, 18%) in TSC1 and from 0 to 100% (median, 39%) in TSC2 patients. A fair correlation (r=.464) was found between patient's age and renal involvement, a good correlation (r=0.655) between renal involvement and creatinine clearance. CONCLUSION: Renal parenchyma of TSC patients can be evaluated with MR imaging. A detectable renal involvement was found in 83% of patients, higher in TSC2 than in TSC1. Renal function seems to correlate with renal involvement quantified with MR imaging.

A prospective comparison of endorectal ultrasound and pelvic magnetic resonance in the preoperative staging of rectal cancer.

BACKGROUND: The development of new surgical modalities (local excision, coloanal-anastomosis) and the diffusion of preoperative neoadjuvant therapy, has increased the importance of an accurate preoperative staging in patients with rectal cancer. The aim of this study was to compare the accuracy of endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI) in the local preoperative staging of rectal carcinoma; moreover the two methods were assessed with a concordance K test. METHODS: Twenty-nine patients with rectal carcinoma were staged with EUS and body coil MRI and then underwent radical surgery. The preoperative staging was compared with the histologic findings of the operative specimen. RESULTS: EUS was more accurate (79.3%), with better sensibility (90%), positive predictive value (PPI9 (85.7%) and negative predictive value (NPV) (25%) than MRI in the evaluation of T parameter. MRI was more accurate (72.4%), with better specificity (81.2%), PPV (72.7%) and NPV (68.4%) than EUS in the evaluation of N parameter. The concordance test obtained a K value of 19.8% for the T parameter and 34.2% for the N parameter. CONCLUSIONS: EUS and MRI are complementary methods in the preoperative staging of rectal cancer. EUS is more accurate in determining bowel wall penetration of the tumor, while MRI is more accurate in the evaluation of lymph node involvement. The low value of the K index confirms the complementarity of the two examinations. Further studies with new imaging techniques such as endocoil MRI, external phase-arrayed coil MRI and three dimensional ultrasound are needed to identify the most effective single examination in the preoperative staging of rectal cancer.

Endoscopic ultrasonography and magnetic resonance in preoperative staging of rectal cancer: comparison with histologic findings.

The development of new surgical techniques and use of neoadjuvant therapy have increased the need for accurate preoperative staging of rectal cancer. We compared the ability of endoscopic ultrasonography (EUS) and two magnetic resonance imaging (MRI) coils to locally stage rectal carcinoma before surgery. Forty-nine patients with histologically proven rectal carcinoma were T and N staged by EUS and either body coil MRI or phased-array coil MRI. After radical surgery, the preoperative findings were compared with histologic findings on the surgical specimen. For T stage, accuracies were 70% for EUS, 43% for body coil MRI, and 71% for phased-array coil MRI. For N stage, accuracies were 63% for EUS, 64% for body coil MRI, and 76% for phased-array coil MRI. For T stage, EUS had the best sensitivity (80%) and the same specificity (67%) as phased-array coil MRI. For N stage, phased-array coil MRI had the best sensitivity (63%) and the same specificity (80%) as the other methods. EUS and phased-array coil MRI provided similar results for assessing T stage. No method provided satisfactory assessments of local N stage, although phased-array coil MRI was marginally better in assessing this important parameter. Although none of the results differed significantly, phased-array coil MRI seems to be the best single method for the preoperative staging of rectal cancer.

[Echocardiographic features in a case of tuberculous lymphadenitis]. / L'ecocardiogramma in un caso di linfoadenite tubercolare.

Tuberculosis can secondarily affect the heart, mainly the pericardium and less frequently the endocardium and coronary vessels. Tuberculous myocarditis usually is a post-mortem diagnosis, and affects the right atrium and left ventricle presenting as miliary granulomas with or without caseating necrosis, or as diffuse cellular infiltration. We report the case of a 65-year-old man, affected by tuberculous lymphadenitis, with a history of hyperkinetic atrial and ventricular arrhythmias. Magnetic resonance, transthoracic and transesophageal echocardiography showed a peculiar cardiac involvement, characterized by right ventricular and left atrial infiltration. As the patient refused myocardial biopsy, the diagnosis of tuberculous myocarditis was stated ex-adjuvantibus, after specific multidrug chemotherapy with complete remission of all echocardiographic abnormalities. Echocardiography represents a useful diagnostic tool in patients presenting with clinical and electrocardiographic features, that even not specific could be suggestive of tuberculous myocarditis, whose incidence could be greater than reported in the literature.

Contrast radiology, computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohn's disease: a prospective comparative study.

OBJECTIVE: Accurate assessment of intestinal complications of Crohn's disease (CD) is extremely important, both in clinical practice and in trials. The accuracy of radiographic and ultrasonographic diagnosis of internal fistulae and abscesses complicating CD is still debated and requires further investigation. We compared ultrasonography (US) and contrast radiography in detecting intestinal fistulae and abscesses complicating CD. METHODS: A prospective study was carried out on 625 consecutive CD patients who underwent complete evaluation of the intestinal tract by means of colonoscopy and double contrast barium enema, small bowel enteroclysis, and abdominal ultrasound (US). Computed tomography (CT) was also carried out in cases of severe CD with clinical suspicion of septic complications. The accuracy of US, barium radiology, and CT in detecting internal fistulae and abscesses was assessed by comparing results with intraoperative findings in 128 consecutive patients who underwent operation immediately after diagnostic workup. RESULTS: Internal fistulae and intra-abdominal abscesses were identified intraoperatively in 56 (43.7%) and 26 (20.3%) patients, respectively. Diagnostic accuracy of US and x-ray studies in detecting internal fistulae was comparable (85.2% vs 84.8%), with sensitivity of 71.4% for US and 69.6% for x-ray studies, and specificity of 95.8% for both. Combination of radiographic techniques and US significantly improved diagnostic accuracy in detection of internal fistulae. In severe cases of CD with clinical suspicion of septic complications such as abdominal mass or fever, the accuracy of US, barium studies, and CT was 88.5%, 80.3%, and 77%, respectively (p = ns). The presence of abscesses was correctly detected in 90.9% of cases by means of US and in 86.4% by CT (p = ns), although accuracy was higher for CT (91.8%) than for US (86.9%) because of false positive results in US studies. CONCLUSIONS: Despite the fact that barium radiology is widely considered the method of choice in detection of internal fistulae, accuracy is not entirely satisfactory. Comparable accuracy was found for US and CT. The combination of barium and US studies, or the sole use of US in more CD patients with more severe disease, can reliably detect most internal fistulae and abscesses.