Contrast Enhanced Ultrasound in CT-undetermined Focal Liver Lesions.

Purpose: The purpose of this study was to examine the diagnostic accuracy of CEUS in the diagnosis of focal liver lesions, which were undetermined at CT scan. Materials and Methods: From January 2010 to December 2010, patients with CT-undetermined focal liver lesions were included in this study. A total of 78 patients were evaluated: 41 men and 37 women, mean age 61.8 years; age range 30-91 years. All patients were examined with GE LOGIQ 9E ultrasound scanners with contrast-specific software, and SonoVue intravenous bolus. The standard of reference was composite consisting of: percutaneous biopsy, surgical resection, PET/CT and clinical follow-up. Results: The 78 included patients had 163 undetermined focal liver lesions, mean size 1.1 cm, range 0.1-5.3 cm. There were 18 malignant and 145 benign liver lesions, as defined by the standard of reference. In differentiating between benign vs. malignant CEUS demonstrated sensitivity, specificity, PPV, NPV and accuracy of 94.4% (95% CI: 56.3-99.5%), 99.3% (95% CI: 94.9 -99.9%), 94.4% (95% CI: 56.3-99.5%), 99.3% (95% CI: 94.9-99.9%) and 98.7% (95% CI: 94.9-99.7%), respectively. If the CEUS-inconclusive results were assumed to indicate malignancy, then sensitivity, specificity, PPV, NPV and accuracy would be 95.8% (95% CI: 66.4-99.6%), 98.6% (95% CI: 94.4-99.7%), 92.0% (95CI: 65.1-98.6%), 99.3% (95% CI: 95.0-99.9%), 98.2% (95% CI: 94.4-99.5%). Conclusion: The results of this study showed a high diagnostic accuracy for CEUS in undetermined focal liver lesions found by CT. Due to a high diagnostic accuracy of CEUS in this study, it was cautiously concluded that CEUS is useful in differentiating between malignant and benign focal liver lesions in clinical practice.

Tetracycline for sclerosis of thyroid cysts. A randomized study.

In a prospective study, 53 consecutive patients with solitary thyroid cysts were randomized to ultrasonically guided cyst aspiration and subsequent flushing with isotonic saline (n = 30) or tetracycline hydrochloride (n = 23). The patients were followed up clinically and ultrasonically 1, 3, 6, and 12 months after treatment. If the cyst recurred, a repeated treatment was offered. Cure was defined as the absence of any residual nodule and an ultrasonic cyst volume of less than 1 mL 12 months after the last treatment. During follow-up, two patients without recurrence after saline treatment and six patients without recurrence after tetracycline treatment developed solid cold nodules. Fourteen (47%) of 30 patients in the saline group and ten (43%) of 23 patients in the tetracycline group were cured (not statistically significant). Tetracycline does not seem to offer any advantage over isotonic saline in the treatment of thyroid cysts, and some of these patients still need thyroid surgery.

Percutaneous ethanol injection therapy in the treatment of thyroid and parathyroid diseases.

Relevant English language articles published from 1966 to 1995 regarding ethanol therapy in the treatment of thyroid and parathyroid diseases were identified through a MEDLINE search and manual searches of identified articles. The sclerosing properties of ethanol have been recognized for many years and have offered interventional possibilities in the management of various benign as well as malignant lesions. The mechanism of action of ethanol appears to be related to a direct coagulative necrosis and local partial or complete small vessel thrombosis. Ultrasound-guided percutaneous ethanol injection therapy (PEIT) is rapid and performed on an out-patient basis and has now gained wide acceptance due to the accumulating evidence of the efficacy and safety of this therapeutic tool. Yet, there is a lack of prospective, randomized clinical trials comparing PEIT with 131I therapy or surgery with regard to its effects, especially long-term ones and it should therefore still be considered an experimental procedure. In benign endocrine diseases, PEIT has shown promising results in the treatment of autonomous thyroid nodules, benign solitary cold solid as well as cystic thyroid nodules and parathyroid tumours. Its use in pretoxic and toxic thyroid nodules has been evaluated in several uncontrolled studies, all demonstrating a high success rate in spite of the large number of treatments needed. So far efficacy and cost-effectiveness seem inferior to 131I and surgery. Short-term results of PEIT in benign cystic thyroid nodules are convincing with a high cure rate, but no controlled studies with long-term results are available. Preliminary results suggest that PEIT could become an alternative to surgical excision or levothyroxine therapy in the symptomatic solid cold benign thyroid nodule. Ultrasound-guided PEIT of parathyroid tumours has proven to be a useful method in highly selected patients in whom surgery has been found non-attractive and medical treatment ineffective. However, no prospective randomized trials have been published comparing the results of PEIT in parathyroid tumours with conventional surgical and medical treatments. PEIT has never been tested against standard therapy, but seems inferior to 131I and surgery. Side-effects caused by ethanol injection are generally few and transient and are related to the injection into solid nodules rather than cysts. Ethanol injection into solid profund nodules may seriously jeopardize subsequent surgery because of perinodular fibrosis. As an experimental procedure, not yet evaluated sufficiently, it should be reserved for patients who cannot or will not undergo standard therapy. Caution in routine use is advisable.

Parathyroid identification by ultrasonically guided aspiration cytology. Is correct cytological identification possible?

Reliable parathyroid identification is necessary before percutaneous inactivation of parathyroid tumours is carried out. Aspiration cytology is one of the methods used for this purpose. Some, but not all, investigators have found it difficult or impossible to make a cytological distinction between thyroid and parathyroid cells. In a blind morphological study of 16 parathyroid and 16 thyroid aspirations the specificity of a cytological diagnosis of parathyroid cells was 100%. The sensitivity of the same diagnosis was 9/16 = 56% if only certain diagnosis of parathyroid cells was considered, but 14/16 = 88% if also diagnoses of "probably parathyroid cells" were considered.

Ultrasound diagnosis of cholangiocarcinoma at the confluence of the hepatic ducts (Klatskin tumours).

The findings on ultrasound of 31 consecutive patients with pathologically proven Klatskin tumours are reviewed. In all patients, ultrasound disclosed dilated intrahepatic bile radicles and normal common bile ducts. A well defined, rounded, solid tumour mass was detected in 11 (35%) patients. Compared with the findings at surgery or autopsy, ultrasound disclosed eight of 12 tumours presenting as extraductal masses. In 16 patients with tumour growth predominantly along the bile ducts, ultrasound disclosed poorly demarcated echogenic tissue high in the hepatic hilum in four cases. In only two patients was it possible to detect tumour spread. Ultrasound-guided, fine-needle aspiration biopsy was performed in seven patients revealing malignant cells in five cases and fine-needle tissue biopsy was performed in two cases revealing malignant tissue. The presence of intrahepatic dilated bile radicles with normal-sized common bile ducts should raise the possibility of a high bile duct carcinoma. If a tumour lesion is detected we suggest the use of ultrasound-guided, fine-needle biopsy.

Technical note: ultrasound guided transvaginal drainage utilizing a 7 French pig tail balloon catheter.

Ultrasound guided transvaginal drainage of abscesses in the small pelvis is usually performed using needles or stiff pig tail catheters without internal fixation. To prevent dislodgement during the subsequent drainage and irrigation procedure, we have developed a new soft 7 F balloon catheter for continuous transvaginal drainage. The catheter is made of soft C-flex and contains two channels, one for drainage and one for inflating a small distal balloon (outer diameter, 10 mm).

Ultrasonic visualisation of the inflamed appendix.

A prospective ultrasonic study of the right lower abdominal quadrant was performed in 46 patients prior to appendicectomy. Ultrasonography revealed an inflamed appendix in 24 out of 29 patients with appendicitis and excluded its presence in 16 out of 17 patients without appendicitis. The ultrasonic pattern of the inflamed appendices appeared as echo-poor/echo-free lesions with lack of movement. In six of seven patients with perforated appendices, ultrasonography revealed free intra-abdominal fluid in addition to bowel disease. The possible value of abdominal ultrasound in patients with suspected acute appendicitis is discussed.

Ultrasound guided laser ablation of a parathyroid adenoma.

We present a case of primary hyperparathyroidism with severe hypercalcaemia, treated successfully with ultrasound (US) guided percutaneous interstitial laser photocoagulation (ILP) of a single parathyroid tumour. To our knowledge, this is the first reported case of ILP applied in primary hyperparathyroidism. US guided thermic tissue coagulation with ILP may be a non-surgical alternative in patients with symptomatic hypercalcaemia due to a parathyroid tumour when surgery is contraindicated.

Ultrasonically guided percutaneous inactivation of parathyroid tumours.

Four patients with hyperparathyroidism and one parathyroid tumour detected ultrasonically were treated by ultrasonically guided percutaneous injection of ethanol (96%) into the tumour. Normocalcaemia was achieved for a follow-up of 10 months in one patient and of 3 months in another. One patient had a lowered serum calcium level for a follow-up of 5 months. One patient showed no clinical response to treatment but was subsequently shown to have multiglandular involvement at surgical exploration. Ultrasonically guided percutaneous inactivation of solitary parathyroid tumours as an alternative to surgery is discussed.

Ultrasound-guided chemical parathyroidectomy in patients with primary hyperparathyroidism: a prospective study.

Twenty of 31 consecutive ultrasound examined patients with primary hyperparathyroidism were selected for treatment with ultrasound-guided percutaneous injection of ethanol (96%) into biopsy-verified solitary parathyroid tumours following a strict protocol with regard to dose, number of treatments and a minimum of 6 months follow-up. Of 18 patients completing the above protocol, a biochemical improvement was observed in 12, of whom eight became normocalcaemic during the follow-up period of 6 months after the last treatment. An obvious clinical improvement was seen in eight of the patients. In four patients, a unilateral vocal cord paralysis was observed, but was permanent in only one patient. Progressive fibrosis of the parathyroid tumours following injections impeded the intraglandular dissemination of ethanol. Another problem noted was the inability of ultrasound to detect multiglandular involvement. We find ultrasound-guided chemical parathyroidectomy an attractive alternative to surgery in patients who are not well suited for surgical intervention. However, the technique has not been fully developed, and in the present study, possible improvements are indicated.

Observer variation in ultrasound assessment of the thyroid gland.

In order to determine observer variation in the assessment of the thyroid gland by ultrasonography, two specialists (one endocrinologist and one radiologist) independently evaluated 76 thyroid glands, and assessed the sonogram as homogeneous, inhomogeneous, containing a solitary solid lesion or a solitary cyst in each of 152 thyroid lobes. The observed agreement between the two observers ranged from 0.80 to 0.91. By the use of the kappa coefficient the observed agreement was adjusted for change agreement. Kappa can vary from -1 (total disagreement) to +1 (total agreement) and kappa values between 0.55 and 0.60 were found. Among 152 lobes a solitary solid lesion, i.e. a nodule, was found in 22 lobes by the two observers; however, they only agreed on a classification in 10 lobes (45%). Clinicians should be aware of the moderate agreement between observers in thyroid ultrasonography.

Ultrasound-guided, histological, fine-needle biopsy from suspect parathyroid tumours: success-rate and reliability of histological diagnosis.

Ultrasound-guided, fine-needle tissue biopsies were performed in 60 suspected parathyroid tumours in 55 consecutive patients with biochemically proven hyperparathyroidism. The specimens were randomly arranged and re-read "blind" by two pathologists. The interobserver agreement, corrected for chance agreement, was 0.92 (= kappa coefficient). Twenty-three of the 60 suspect parathyroid tumours were verified histologically following surgery. No diagnostic errors were seen but the percentage of insufficient biopsies from suspect parathyroid tumours or surgically verified parathyroid tumours was high (45 and 47%, respectively). We conclude that a reliable tissue diagnosis can be made by ultrasound-guided, fine-needle tissue biopsy. However, when the material is insufficient for histological diagnosis, we recommend the additional use of ultrasound-guided, fine-needle aspiration for cytology or parathyroid hormone determination.

Concomitant thyroid disease in hyperparathyroidism. Reasons for unsatisfactory ultrasonographical localization of parathyroid glands.

Ultrasonic localization of enlarged parathyroid glands has been attempted in a consecutive series of 23 patients with primary hyperparathyroidism. Seven of 15 patients with operatively verified diagnosis, had predictive ultrasound scans (47% consistency) and 10 of 16 adenomas were identified (63%). A possible explanation for these unsatisfactory results could be a high incidence of coexisting nodular thyroid lesions, and significantly enlarged thyroid glands in these patients.

[Intraoperative ultrasonic scanning during hepatic, biliary and pancreatic surgery]. / Intraoperativ ultralydskanning ved lever-, galde- og pancreaskirurgi.

Intraoperative ultrasound (US) is one of the most recent applications of US technology. Intraoperative US is currently used within several surgical fields. Intraoperative US may better define the normal anatomy and target pathology than preoperative studies. The method has proved to be an attractive diagnostic tool in surgery of the biliary tract, pancreas and liver. However, one difficulty that has prevented general acceptance of the method is the surgeon's unfamiliarity with the use of diagnostic ultrasound. In order to obtain successful outcome of intraoperative US, close cooperation between the surgeon and the ultrasonologist is essential.

[Pulmonary arteriovenous malformations determined by color Doppler ultrasonography]. / Pulmonale arteriovenøse misdannelser påvist ved farve-Doppler-ultralydundersøgelse.

Pulmonary arteriovenous malformations are rare conditions, and are often misinterpreted on chest radiographs. We present a case in which peripherally localised pulmonary arteriovenous malformations were diagnosed by use of colour-Doppler ultrasonography.

[Contrast media in ultrasonography]. / Kontraststoffer til brug for UL-diagnostik.

Microbubbles of air or other gases are ideally suited as echo-enhancers because of the high difference in acoustic impedance of gas/fluid interfaces. The microbubbles are 1-7 microns in diameter and capable of surviving pulmonary passage to produce enhancement of especially the Doppler signal after intravenous injection. The main clinical role of ultrasound (US)-contrast is to enhance the Doppler signals (up to 20 dB) in inconclusive Doppler examinations. Experience with US-contrast agents comes mainly from use of the galactose based agent Levovist (Schering AG, Germany). The US-contrast agents have further properties: a) Air bubbles in the sound fields will reverberate and return sound with harmonic frequencies. This phenomenon can be used in "harmonic imaging". B) Short intense sound impulses will destroy the bubbles resulting in a mosaic of colours (stimulated acoustic emission). This phenomenon may be used in tumour diagnostics in the liver.

[Ultrasonically guided pericardiocentesis]. / Ultralydvejledt draenage af perikardiehulen.

Ultrasonically guided pericardiocentesis was performed on 25 occasions in 23 consecutive patients. Incipient cardiac tamponade was present in 22 patients and the procedure was performed for diagnostic purposes in one patient. In 21 cases, 5.7 French pig-tail catheters were employed and 1.2 mm lumbar puncture needles in four cases. In 19 out of 22 patients (86%) with incipient cardiac tamponade the ultrasonically guided pericardiocentesis was considered successful. In one patient, the catheter was misplaced in the right atrium, one patient developed pyopericardium and one patient developed transient tachycardia. In two cases, no material could be obtained. Ultrasonically guided pericardiocentesis is preferable to "blind" puncture and the procedure should be carried out by physicians with experience in interventional ultrasound.

Ultrasonically guided fine-needle biopsies from adrenal tumors.

Ultrasonically guided fine-needle biopsies were performed from 28 adrenal lesions in 28 patients. In 15 patients adrenal enlargement was an incidental finding. In 17 of 18 (94%) patients with metastatic spread combined cytological and histological examination disclosed secondary malignancy, and in 4 of 5 patients with primary neoplastic disease the combined microscopic examination concluded primary neoplasia. However, it was not possible to classify these lesions as being of a malignant or a benign nature. A false positive diagnosis of a hepatocellular carcinoma of the clear cell type was made in one case. In all 5 patients with non-neoplastic adrenal lesions cytological and histological examinations concluded non-neoplastic disease. Electron microscopy was of special benefit in two cases of a non-Hodgkin's lymphoma and a pheochromocytoma. Using ultrasonically guided biopsies it is possible to differentiate between adrenal lesions due to metastatic spread and adrenal lesions due to primary neoplasia or non-neoplastic disease. Compared to other imaging techniques ultrasonically guided punctures of adrenal masses is a simple procedure giving important diagnostic information.