How to manage type 2 curve dilemma in dynamic contrast-enhanced magnetic resonance imaging of the breast: diffusion-weighted imaging or early phase enhancement kinetics?

BACKGROUND: Type 2 time-intensity curves can indicate both malignant and benign breast lesions in dynamic contrast enhanced magnetic resonance imaging (DCE-MRI). PURPOSE: To investigate whether diffusion-weighted imaging (DWI) or early phase kinetics of DCE-MRI is practical to discriminate breast masses that depict type 2 curve in DCE-MRI. MATERIAL AND METHODS: We retrospectively included 107 lesions in 97 patients with type 2 curves in DCE-MRI. Morphological characteristics, early phase dynamic parameters on DCE-MRI, and apparent diffusion coefficient (ADC) values on DWI were evaluated. Diagnostic thresholds of ADC and early phase maximum enhancement ratio (EPMER) to distinguish between benign and malignant masses were calculated. Strongest predictors of malignancy were determined to build the most effective diagnostic model. RESULTS: DWI, EPMER, and all morphological features were found statistically significant to discriminate malignancy (P <0.05). The thresholds of ADC and EPMER were assigned as 1.0 ×10-3 mm2/s and 72%, respectively. The sensitivity and specificity were 80% and 97% for ADC, and 93% and 60% for EPMER, respectively. Two models were established. Model 1 comprised ADC and the lesion margin. Model 2 consisted of ADC, margin, and EPMER with a high specificity (99%) and positive predictive value (97%). CONCLUSION: When combined with DWI, early phase wash-in data provide diagnostic improvement of breast masses presenting type 2 curve in the late phase of DCE-MRI, especially for specificity. Future studies are required to support our findings for the need of a cross-validation.

The Impact of Prostate Imaging Reporting and Data System Version 2.1 and Prostate-Specific Antigen Density in the Prediction of Clinically Significant Prostate Cancer.

OBJECTIVE: The aim of this study was to evaluate the diagnostic performance of multiparametric magnetic resonance imaging for clinically significant prostate cancer and to determine whether applying Prostate Imaging Reporting and Data Systems version 2.1 score could improve the diagnostic pathway besides the biochemical characteristics. MATERIALS AND METHODS: In this study, 199 patients with clinically suspected prostate cancer who underwent multiparametric magnetic resonance imaging were included. Logistic regression analyses and receiver operating characteristic curve were performed to determine independent predictors and to compare diagnostic performance of indicators for clinically significant prostate cancer. Two models were established. In model 1, the diagnostic performance of prostate-specific antigen- and prostatespecific antigen density-derived parameters were evaluated. In model 2, the prediction potential of model 1 plus Prostate Imaging Reporting and Data Systems version 2.1 score was analyzed. RESULTS: Sixty-four patients were positive for clinically significant prostate cancer by histopathological analysis (32.1%). In model 1, a prostate-specific antigen density >0.15 was labeled as the strongest predictor of malignancy. In model 2, a prostatespecific antigen density >0.15, a Prostate Imaging Reporting and Data Systems score ≥3, and a Prostate Imaging Reporting and Data Systems score ≥4 demonstrated the strongest association with malignancy. Among these parameters, a Prostate Imaging Reporting and Data Systems score ≥4 (P=.003) was found to be the most robust predictor for malignancy, followed by a Prostate Imaging Reporting and Data Systems score ≥3 (P=.012). The multivariate analysis revealed higher accuracy in model 2 (76.9%) than in model 1 (67.8%). The area under curve values with respect to prostatespecific antigen, prostate-specific antigen density, model 1, and model 2 were 0.632, 0.741, 0.656, and 0.798, respectively. CONCLUSION: These results indicated that Prostate Imaging Reporting and Data Systems version 2.1 score and prostate-specific antigen density are independent predictors for the presence of clinically significant prostate cancer. Both prostate-specific antigen density and Prostate Imaging Reporting and Data Systems version 2.1 score should be risen to prominence in the decision of biopsy instead of PSA.

Value of the newly developed pelvic dimension index/prostate volume ratio in predicting positive surgical margin in prostate cancer.

PURPOSE: To evaluate the diagnostic performance of pelvimetric measurements, in particular the pelvic dimension index (PDI)/prostate volume (PV) ratio (PDI/PV), in predicting positive surgical margin (PSM) in prostate cancer (PC). MATERIALS AND METHODS: 127 patients who had pre-operative pelvic imaging were included in this study. Demographic and clinical data were recorded. Apical depth (AD), interspinous distance (ISD), intertuberous distance (ITD), bony femoral width (BFW), soft-tissue width (SW), symphysis angle (SA), anteroposterior diameter of the pelvic inlet (API), anteroposterior diameter of the pelvic mid-plane (APM), anteroposterior diameter of the pelvic outlet (APO), pelvic depth (PD), bony width index (BWI), soft tissue width index (SWI), pelvic cavity index (PCI), PDI and PV were measured on MRI or CT. Using PDI and PV, we developed a new parameter of "PDI to PV ratio" (PDI/PV). Logistic regression analysis was used to determine the predictive potential of variables in detection of PSM. RESULTS: The AD, PV, SA and total prostate specific antigen (PSA) were significantly higher in PSM( +), while PDI, BWI, SWI, API, PDI/PV and PD were significantly lower in PSM( +) (p < 0.05). In multivariate analysis, PDI/PV ratio and clinical stage were all significant predictor of PSM, where PDI/PV ratio was the strongest predictor, followed by clinical stage. CONCLUSION: Pelvimetric measurements indicating deep location of the prostatic apex rather than pelvic width are more effective in predicting PSM. Prediction of PSM with pelvimetric measurements, in particular PDI/PV ratio, may be helpful for surgical planning in preoperative period.

Doppler ultrasonography blood flow changes of the hepatic artery in liver transplants complicated with cholangitis.

PURPOSE: Cholangitis after liver transplantation may lead to bile duct necrosis. Early diagnosis is essential to prevent graft loss. We aimed to investigate cholangitis related hepatic arterial Doppler ultrasonography findings in liver transplants. METHODS: Patients complicated with biopsy proven cholangitis in grafts were prospectively evaluated. Vascular complications were excluded. Doppler ultrasonography parameters including hepatic arterial diameter, resistive index, volume flow, and portal vein maximum velocity were measured twice: first during cholangitis and after full recovery. Data of two groups were compared using paired samples t test and Mann-Whitney U test. RESULTS: The mean hepatic arterial volume flow, resistive index, and diameter of 33 patients complicated with cholangitis was observed to decrease after recovery from 0.356 to 0.273 L/min (p = 0.007), from 0.64 to 0.60 (p < 0.001) and from 4.9 to 4.4 mm (p < 0.001), respectively. Portal vein maximum velocity alteration was not statistically significant (p = 0.6). CONCLUSION: Ultrasound follow-ups after liver transplantation can give us the clue of cholangitis initiation through some altering hepatic arterial Doppler parameters. Even though these are nonspecific findings that can also be observed in vascular complications, baseline Doppler data should be saved for future comparison and considered to prevent biliary associated graft loss.

Ultrasonographic and electrophysiological outcomes of carpal tunnel syndrome treated with low-level laser therapy: A double-blind, prospective, randomized, sham-controlled study.

Objectives: The aim of this study was to investigate the therapeutic effects of low-level laser therapy (LLLT) on clinical, ultrasonographic (US), and electrophysiological findings in carpal tunnel syndrome (CTS). Patients and methods: Between January 2015 and August 2015, 42 patients (7 males, 35 females; mean age: 50.4±8.7 years; range, 32 to 65 years) with mild-to-moderate CTS were randomly assigned to one of two groups: active LLLT (therapy group, n=22) 0.8 J/painful point and sham LLLT groups (n=20). Both groups wore neutral wrist orthoses. The patients were evaluated before and after 15 sessions of therapy (670 nm, 4 J/session over the carpal tunnel). Follow-up parameters included the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) Symptom Severity Scale (SSS), Functional Status Scale (FSS), nerve conduction studies and US evaluation of the median nerve cross-sectional area (CSA), vascularization (via power Doppler), flattening ratio (FR), and palmar bowing of the flexor retinaculum. Results: Nocturnal paresthesia improved in both groups; however, pain and patients with a positive Phalen's test reduced only in the therapy group (p=0.031). The FSS and SSS scores also improved only in the therapy group (p<0.001). Electrophysiologically, median sensory nerve conduction velocities showed a significant improvement only in the therapy group (p=0.002). The CSA, FR, and vascularization of the median nerve showed a significant improvement in the therapy group alone (p<0.001, p=0.048, and p=0.021, respectively). Conclusion: Improvements in the signs and symptoms of CTS and hand function, the improvements in sensory nerve conduction studies, and reduction in median nerve CSA, FR and vascularity in the LLLT group can be attributed to the anti-inflammatory and analgesic effects of LLLT. This study provides new US data demonstrating efficacy of LLLT along with a clinical and electrophysiological improvement. The LLLT seems to be an easily applied, non-invasive treatment option.

Effect of meal intake for evaluating hepatic artery by Doppler ultrasonography in liver transplants: Does fasting matter for screening hepatic artery due to hemodynamic changes in splanchnic circulation?

PURPOSE: The aim of this study is to assess the utility of fasting on Doppler ultrasonography findings of hepatic artery in liver transplants. METHODS: Liver transplant patients without vascular abnormalities were prospectively evaluated between December 2017 and January 2020. Doppler sonography was used to describe hemodynamic changes in response to a standard meal. The diameter, peak systolic velocity, blood flow, resistive index (RI) of the main hepatic artery and portal vein peak velocity were measured. RESULTS: The mean hepatic arterial diameter of 44 patients was higher in the fasting group (4.5 mm) than in the postprandial group (3.3 mm) (p < .05). The mean hepatic arterial blood flow decreased (from .276 to .127 L/min) and hepatic arterial RI increased (from .66 to .71) following meal ingestion (p < .05). Hepatic arterial velocity was significantly lower and portal venous velocity was higher after oral intake. CONCLUSION: Meal ingestion has an important effect on hepatic artery Doppler features in liver transplants. Therefore, Doppler ultrasound evaluation should be considered after appropriate fasting due to postprandial responses of liver transplant.

Portal Venous Flow Alterations in Hepatic Artery Thrombosis Following Liver Transplant.

OBJECTIVES: The hepatic vasculature is a unique system due to a dual supply that includes the hepatic artery and portal vein, which interact when the liver vascular supply is decreased. Hepatic artery buffer response, an intrinsic regulatory mechanism that compensates for blood supply, maintains increased hepatic artery flow and caliber in response to portal vein failure. Previous studies revealed that portal vein flow showed no alterations to establish adequate blood supply in response to hepatic artery occlusion. Here, we analyzed portal vein flow changes in patients with hepatic artery thrombosis after liver transplant. MATERIALS AND METHODS: From December 1988 to October 2017, our center performed 580 liver transplant procedures. Those diagnosed with hepatic artery thrombosis (19 females, 24 males) by Doppler ultrasonography during postoperative week 1 were analyzed. Patients received either surgery or endovascular treatment for hepatic artery thrombosis, with patency confirmed by Doppler ultrasonography. We compared portal vein flow velocity and caliber before and after treatment using Wilcoxon signed rank and Mann Whitney U tests. RESULTS: Mean patient age was 18.9 ± 21.4 years. Portal vein flow velocity pretreatment (median of 70 cm/ s) was significantly higher than posttreatment (median of 52 cm/ s) in all patients (P < .001). Median flow velocity decreased significantly after treatment when subgroups were compared, including age (adult vs child), transplant type (orthotopic transplant vs living donor), and treatment (surgery vs endovascular). However, portal vein flow velocity showed a significantly higher decrease in the surgery subgroup than in the endovascular treatment subgroup (P = .018). There was no significant relationship between portal vein calibers before and after treatment (P = .36). CONCLUSIONS: The significant decrease in portal vein flow velocity after successful treatment of hepatic artery thrombosis may represent a compensatory flow change of the portal vein in response to diminished hepatic artery flow.

The Role of Combined Diffusion-Weighted Imaging and Dynamic Contrast-Enhanced MRI for Differentiating Malignant From Benign Breast Lesions Presenting Washout Curve.

PURPOSE: The aim of this study is to evaluate the diagnostic performance of combined breast magnetic resonance imaging (MRI) protocol including dynamic contrast-enhanced MRI (DCE-MRI) and diffusion-weighted imaging (DWI) in patients with enhancing lesions that demonstrated washout curve and to determine whether applying apparent diffusion coefficient (ADC) cutoff value could improve the diagnostic value of breast MRI. METHODS: The retrospective study included 116 patients with 116 suspicious breast lesions, which showed washout curve on DCE-MRI, who underwent subsequent biopsy. Morphologic characteristics on DCE-MRI and ADC values on DWI were evaluated. Apparent diffusion coefficient values and morphologic features of benign and malignant lesions were compared. Diagnostic values of DCE-MRI and combined MRI, including DCE-MRI and DWI (applying an ADC cutoff value) for distinguishing malignancy from benign lesions, were calculated. RESULTS: Of the 116 breast lesions, 79 were malignant and 37 were benign. The ADC value of malignant tumors (median ADC, 0.72 × 10-3 mm2/s) was significantly lower than that of benign lesions (median ADC, 1.03 × 10-3 mm2/s; P < .000). The sensitivity and specificity of an ADC cutoff value of 0.89 × 10-3 mm2/s were 92% and 95%, respectively. Dynamic contrast-enhanced MRI alone presented 100% sensitivity and 59.4% specificity. Adding an ADC cutoff value of 0.89 × 10-3 mm2/s provided 100% sensitivity and 81% specificity, which would have prevented biopsy for 21.6% of benign lesions without missing any malignancies. CONCLUSION: Applying an ADC cutoff value to DCE-MRI provides an improvement in the diagnostic value of breast MRI for differentiating among lesions presenting washout curve.

Diffusion-Weighted Imaging of Breast Cancer: Correlation of the Apparent Diffusion Coefficient Value with Pathologic Prognostic Factors.

OBJECTIVE: The aim was to evaluate relationship between apparent diffusion coefficient (ADC) values with pathologic prognostic factors in breast carcinoma (BC). MATERIALS AND METHODS: 83 patients were enrolled in this study. Prognostic factors included age, tumor size, expression of estrogen receptor (ER) and progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2), nuclear grade (NG), lymph node involvement and histologic type. The relationship between ADC and prognostic factors was determined using Independent sample t-test, ANOVA, Pearson correlation and relative operating characteristics (ROC) analysis. RESULTS: There was no significant difference between ADC and prognostic factors, including age, tumor size, ER, HER2 and histologic type. The PR-positive tumors (p=0.03) and axillary lymph node involvement (p=0.000) showed a significant association with lower ADC values. The ADC values were significantly lower in high-grade tumors than low-grade tumors (p=0.000). ROC analysis showed an optimal ADC threshold of 0.66 (×10-3 mm2/s) for differentiating low-grade tumors from high-grade tumors (sensitivity, 85.5%; specificity, 81%; area under curve, 0.90). CONCLUSION: The lower ADC values of BC were significantly associated with positive expression of PR, LN positivity and high-grade tumor. Especially, ADC values were valuable in predicting NG subgroups.

Carpal Tunnel Syndrome: Evaluation of the Effects of Low-Level Laser Therapy With Ultrasound Strain Imaging.

OBJECTIVES: To evaluate the efficacy of low-level laser therapy on median nerve stiffness by using strain elastography in carpal tunnel syndrome (CTS). METHODS: This study included 37 wrists of 34 patients with mild or moderate CTS between January 2016 and August 2016. The control group comprised 17 patients (18 wrists) with CTS who were treated with wrist splinting for 3 weeks. The low-level laser therapy group included 17 patients (19 wrists) with CTS who were treated with a combination of splinting and low-level laser therapy, which was applied 5 times per week for 3 weeks. Clinical assessment scales, including the Symptom Severity Scale (SSS) and Functional Status Score (FSS), were obtained from our database. The cross-sectional area by ultrasound and strain ratio by elastography were studied. The differences in the strain ratio, cross-sectional area, SSS, and FSS between pretreatment and posttreatment periods in the groups were compared by the paired-sample t test. The correlations between changes in the strain ratio and the cross-sectional area, SSS, and FSS were analyzed by Pearson correlation coefficients. RESULTS: The control group included 13 women and 4 men, and the therapy group included 14 women and 3 men. In the therapy group, the mean values of the strain ratio, cross-sectional area, SSS, and FSS decreased significantly after laser therapy (P < .001) in contrast to the control group. No significant correlation was observed between the decreasing degree of the strain ratio and the cross-sectional area, SSS, and FSS after laser therapy. CONCLUSIONS: The strain ratio and cross-sectional area of the median nerve decrease after low-level laser therapy. These changes may be related to the therapeutic effects of low-level laser therapy, such as nerve regeneration and improvement of the vascular supply.

Ultrasonography Findings of Urinary Tract Infection After Kidney Transplant: A Case Report.

Urinary tract infection is the most common complication after kidney transplant and often is associated with graft loss and mortality. Ultrasonography is the most widely applied imaging modality for diagnosis of complications after kidney transplant. Here, we report a case of a 52-year-old male patient who underwent renal transplant 1 month earlier and who presented with fever, leukocytosis, and leukocyturia. Klebsiella pneumoniae was found in the urine and blood cultures. Ultrasonography revealed multiple, ill-defined margined, hypoechoic areas and cysts within the cortex. Both clinical findings and ultrasonography findings were resolved after antimicrobial therapy. One month later, the patient presented again with fatigue, leukocytosis, and leukocyturia. Blood and urine culture results were consistent with Klebsiella pneumoniae. Ultrasonography revealed large hypoechoic mass, including multiple cysts in the upper pole of the transplanted kidney. Doppler ultrasonography showed increased vascularity within the hypoechoic mass and surrounding parenchyma. Renal parenchymal echogenicity was also increased in the upper pole. Ultrasonography-guided percutaneous drainage was performed. Clinical, laboratory, and ultrasonography findings were resolved after antimicrobial therapy. Ultrasonography plays an important role in the diagnosis and evaluation of the treatment response of urinary tract infections after kidney transplant.

Ultrasonography Findings of Acute Tubulointerstitial Nephritis and Multiple Abscesses Following Renal Transplant: A Case Report.

Urinary tract infection is the most common complication after kidney transplant that can cause graft loss. An early diagnosis of urinary infections decreases morbidity and mortality. Besides clinical and laboratory examinations, ultrasonography is considered as the primary imaging modality for the diagnosis of urinary tract infections. Here, we report a 53-year-old woman who presented with fever and pain at surgical site. Ultrasonography examination showed multiple, ill-defined or irregularly margined hypoechoic areas within the cortex. Ultrasonography-guided percutaneous renal biopsy was performed. Histopathologic findings were compatible with acute tubulointerstitial nephritis and multiple abscesses. Ultrasonography is the most widely applied imaging modality for diagnoses of complications after renal transplant. Although ultrasonography findings of infections are generally nonspecific, it still plays an important role in the diagnosis of urinary infections after renal transplant.