Dynamic evaluation and quantification of microvascularization during degradable starch microspheres transarterial Chemoembolisation (DSM-TACE) of HCC lesions using contrast enhanced ultrasound (CEUS): a feasibility study

PURPOSE

To evaluate the time dependent changes of microcirculation in hepatocellular carcinoma (HCC) lesions during degradable starch microsphere (DSM)-TACE using contrast enhanced ultrasound (CEUS).

MATERIALS AND METHODS

A total of 48 CEUS examinations were performed (1-5 MHz, convex probe) in 6 selected patients who underwent DSM-TACE with EmboCept®S for the treatment of HCC lesions. I.v. application of ultrasound contrast media was performed before and 24 hours post embolization. In addition i.a. contrast application was performed via the angiographic catheter right before and after the embolization and during a follow up time of 2 hours every 30 minutes. The capillary circulation of the treated HCC lesions was analyzed and quantitative perfusion analysis was performed using a perfusion software by two experienced radiologists in consensus.

RESULTS

A significantly reduced microvascularization was seen right after DSM-TACE in all cases using CEUS. The reduction of PEAK, RBV (regional blood volume) and RBF (regional blood flow) compared to preembolization values was highly significant. Mean PEAK was 34.3 ± 13.1 prior to embolization and 9.4 ± 9.1 post embolization (p < 0.001). Mean RBV was 446.5 ± 122.4 prior to embolization and 70.9 ± 23.8 post embolization (p < 0.001). The corresponding figures for RBF were 34.7 ± 13.4 prior- and 4.8 ± 3.4 post embolization (p < 0.001). During follow up a stepwise revascularization of the lesions was documented: 90 minutes post embolization perfusion parameters were not significantly different from prae-embolization values.

CONCLUSION

In this feasibility study, capillary perfusion quantification of HCC lesions after DSM-TACE could be demonstrated using CEUS. Using quantitative perfusion analysis it was possible to quantify the transient embolizing effect of DSM-TACE.

Degradable starch microspheres transarterial chemoembolisation (DSM-TACE) of HCC: Dynamic Contrast-Enhanced Ultrasonography (DCE-US) based evaluation of therapeutic efficacy using a novel perfusion software

PURPOSE

To evaluate therapeutic efficacy of degradable starch microsphere (DSM)-TACE in hepatocellular carcinoma (HCC) using Dynamic Contrast-Enhanced Ultrasonography (DCE-US) based perfusion analysis.

MATERIALS AND METHODS

A total of 60 DCE-US examinations were performed in 15 selected patients who underwent DSM-TACE with EmboCept®S for the treatment of advanced HCC. DCE-US was performed via i.v. application of ultrasound contrast media before and 24 hours post embolization. In addition DCE-US was performed with i.a. contrast application via the angiographic catheter right before and after the embolization. Microcirculation of embolized HCC lesions was quantified using a dedicated perfusion software by two experienced radiologists in consensus.

RESULTS

Significant reduction of microvascularization (PE, WiAUC and WiR) was seen right after DSM-TACE and during 24 hour follow-up. Mean PE was 342.22 ± 97.80 prior to embolization, 59.28 ± 29.74 post embolization (p = 0.019) and 18.83 ± 7.03 during follow-up (p ≤ 0.01). Mean WiAUC was 1103.21 ± 432.05 prior to embolization 267.69 ± 151.80 post embolization (p = 0.023) and 105.10 ± 44.43 during 24 hour follow-up (p ≤ 0.01). The corresponding values for WiR were 224.91 ± 57.97 prior-, 38.14 ± 18.80 post embolization (p = 0.034) and 6.97 ± 2.68 during follow up (p ≤ 0.01).

CONCLUSION

In this study, therapeutic efficacy of DSM-TACE in HCC using DCE-US based perfusion analysis could be demonstrated.

High resolution ultrasound including elastography and contrast-enhanced ultrasound (CEUS) for early detection and characterization of liver lesions in the humanized tumor mouse model

PURPOSE

In this study we investigated the sensitivity of high resolution ultrasound (HRU) in the detection of small liver tumors and its microcirculation in a humanized tumor mouse model (HTM). These mice develop a complete human immune system and human breast cancer growth in the liver which allows the investigation of antibody based immunotherapies under human like conditions.

METHOD

HTM were generated by the co-transplantation of human breast cancer cells and human hematopoietic stem cells. HRU, Doppler sonography (CCDS), contrast enhanced ultrasound (CEUS) and color-coded elastography were performed on all HTM and confirmed by histopathological assessment.

RESULTS

Using HRU and CEUS, noncystic solid liver lesions between 2 and 11 mm (mean 3.5 mm) size were detectable in HTM. Granulomatous areas were identified by B-scan imaging, showing areas of higher stiffness in elastography and areas without contrast media uptake in the late phase (CEUS). In addition, CEUS detected capillary microcirculation of benign and malignant liver lesions smaller than 10 mm.

CONCLUSION

Beyond human breast cancer HTM additionally developed small parenchymal liver lesions, which could be characterized by HRU in combination with CEUS and elastography in-vivo. Nevertheless, the defined diagnoses of solid liver lesions less than 5 mm require confirmation by histopathology.

First results of endocavity evaluation of the microvascularization of malignant prostate tumors using contrast enhanced ultrasound (CEUS) including perfusion analysis: first results

AIM

Detection of prostate cancer lesions using transrectal contrast enhanced ultrasound (CEUS) of the prostate utilizing quantitative perfusion analysis.

METHOD

20 patients (mean age 63 years, 47-71) with biopsy proven prostate cancer underwent transrectal ultrasound (TRUS) prior to radical prostatectomy by 2 experienced examiners using a multifrequency endocavitary probe (5-9 MHZ, LOGIQ E9, GE Healthcare, Chalfont St Giles, UK) to detect cancer-suspect lesions. CEUS was performed dynamically up to 3 Min after bolus injections of 2.4 ml SonoVue® (BRACCO, Italy). Digital cine loops were analyzed by an independent blinded examiner using perfusion quantification software with colour-coded parametric images in order to define suspect regions based on the perfusion-related parameters early wash in rate (WIR), mean transit time (MTT) and rise time (RT). The results of CEUS perfusion analysis were compared with the histopathology after surgery, obtained from whole mount sections.

RESULTS

After prostatectomy and histopathology, 34 prostate cancer foci were found in 20 patients. In 30/34 cases an early enhancement within the tumor was detected by CEUS perfusion analysis without early wash out. By evaluating the MTT and RT tumor detection was possible in 29/34 and 25/34 cases. The highest detection rate of prostate cancers was obtained by analysis of early contrast enhancement (priot to the normal prostate parenchyma), with a sensitivity of 88%, specificity 100%, NPP 60%, PPV 90%, in clinically suspicious cases with good correlation to the postoperative histopathological findings (r = 0.728).

CONCLUSION

This pilot study demonstrates, that quantitaive analysis of perfusion parameters obtained with transrectal CEUS could be helpful for characterization of neoplastic microcirculation of prostate cancer, for preoperative localization of cancer-suspect areas and for therapy guidance and management.

Percutaneous irreversible electroporation (IRE) of hepatic malignant tumours: contrast-enhanced ultrasound (CEUS) findings

PURPOSE

The aim of this study is to describe the image findings of contrast-enhanced ultrasound (CEUS) after irreversible electroporation (IRE), and to assess its usefulness in relation to the evaluation of the ablation status using a dynamic recording of the microvascularisation.

MATERIAL AND METHOD

In this prospectively designed study, a percutaneous IRE was performed for the treatment of malignant hepatic lesions in a total of 15 patients following the interdisciplinary diagnosis. The lesions were documented using CEUS before, immediately after and 20 minutes after the ablation. The acquired CEUS image data was subsequently independently retrospectively evaluated by 2 experienced radiologists and assessed in relation to microvascularisation using a 5 point scale.

RESULTS

Using CEUS, a significant reduction in the microcirculation of the lesions, both centrally and marginally, could be detected following IRE (p < 0.001 and p < 0.001). The mean evaluation of the central microcirculation was reduced from 3.13 ± 1.38 to 0.47 ± 0.64 (p < 0.01). For the peripheral area of the lesion and the ablation margin, there was a reduction of 3.37 ± 1.13 to 1.57 ± 0.46 (p = 0.001). There was no significant reduction in the macrocirculation.

CONCLUSION

Within the framework of this study, it could be demonstrated that, in the course of IRE, a rapid significant reduction of the microcirculation in the ablation area occurred.

Quantitative assessment of bone microvascularization after osteocutaneous flap transplantation using contrast-enhanced ultrasound (CEUS)

BACKGROUND

Extensive wound defects frequently have to be covered by free flap transplantation. A monitoring device for measuring capillary level perfusion of bone is currently not available.

OBJECTIVE

The aim of the study was to detect complications after osteocutaneous flap transplantation using contrast-enhanced ultrasound (CEUS). Additionally quantitative analysis was performed by special perfusion software (QONTRAST®; Bracco, Italy).

METHODS

22 patients were examined after osteocutaneous flap transplantation during the first 72 h after operation. CEUS was performed with a linear transducer (6-9 MHz, LOGIQ E9/GE) after bolus injections of 2.4 ml ultrasound contrast agent (SonoVue®; Bracco, Italy). The osseous perfusion and soft tissue perfusion were analyzed separately and quantitative perfusion analysis was performed. Five patients had to undergo reoperation due to compromised flap microvascularization.

RESULTS

In all 5 complications reduced osseous and soft tissue perfusion was seen using CEUS. Additionally using the perfusion parameters TTP (time to PEAK), RBV (regional blood volume), RBF (regional blood flow) und MTT (mean transit time), significantly lower soft tissue and osseous perfusion was detected.

CONCLUSION

CEUS seems to be capable of detecting vascular disturbances and of assessing microvascularization of the osseous component after osteocutaneous flap transplantation.

Tissue-specific expression of occludin, zona occludens-1, and junction adhesion molecule A in the duodenum, ileum, colon, kidney, liver, lung, brain, and skeletal muscle of C57BL mice

Tight junctions are the most apically positioned intercellular junction and play many roles such as securing adjacent cells, forming barriers from extracellular materials, and facilitating paracellular transport. Occludin and junction adhesion molecule A (JAM-A) are classified as transmembrane proteins that are directly involved in paracellular transport. Zona occludens-1 (ZO-1) is a protein that contains a PDZ domain which forms a binding site for other tight junction proteins. In this study, we assessed the differential expression of these tight junction components in various mouse organs including the intestine (duodenum, ileum, and colon), kidney, liver, lung, brain, and skeletal muscle. Realtime PCR and Western blot assays were performed to measure the gene and protein expression of occludin, JAM-A, and ZO-1. Similar levels of occludin gene expression were detected in all tissues except for skeletal muscle in which occludin expression was not found. The JAM-A and ZO-1 genes were highly expressed in all the tested tissues. Localization of occludin, JAM-A, and ZO-1 was determined by immunohistochemistry. These proteins were detected in the intercellular apical junctions in each tissue except for occludin (which was not observed in skeletal muscle). These immunostaining data were consistent with the gene expression profiles we obtained. Our results suggest that occludin, JAM-A, and ZO-1 genes are normally expressed in the intestine, kidney, liver, lung, and brain indicating that these factors may be essential for maintaining appropriate physiological concentration of ions, solutes and water.

323 PRODUCTION OF Mx2-TRANSGENIC PIGS FOR INFLUENZA STUDY

A worldwide flu pandemic occurred in 2009, resulting in many victims and high social damages. In the A (H1N1) virus spreading process, the pig is the intermediate host, and this virus is amplified and genetically changed through recombination in pigs. The objective of this study was to develop influenza-resistant pigs. In interferon-α and interferon-γ treated cells, the porcine Mx2 protein has been observed near the nuclear envelope, which consequently has been linked with inhibition of influenza virus proliferation. Therefore, we attempted to produce transgenic (TG) pigs overexpressing the Mx2 gene by somatic cell nuclear transfer (SCNT). Porcine fetal fibroblasts were transfected with the cytomegalovirus vector, which includes the porcine Mx2 gene. The established transgenic cell was injected into the enucleated ooplasm to produce Mx2-TG cloned embryos. In total, 511 female TG porcine embryos were transferred to 5 surrogates. Two recipients were diagnosed pregnant (pregnancy rate, 40%) on Day 25. On Day 114, 6 fetuses and 4 mummies were collected. The PCR analysis concluded that there was no integration of the Mx2 gene. Then, a male Mx2-TG cell line was established to use as donor cell of SCNT. In total, 547 male TG-SCNT embryos were produced. Of these, 38 embryos were cultured in vitro to confirm the developmental capacity of the embryos. Among these porcine SCNT-TG embryos, 26 embryos (68.4%) cleaved and 5 (13.2%) developed to the blastocyst stage. The PCR analysis confirmed that all male TG-SCNT blastocysts were for integration of the Mx2 gene. The remaining 509 male embryos were transferred to 5 surrogates. Two recipients (pregnancy rate, 40%) were diagnosed pregnant at Day 25. To date, 1 of the surrogate has maintained pregnancy and another recipient gave birth to 9 piglets. Two days after birth, 2 piglets died and the remaining piglets remain healthy. Verification analysis of gene targeting and resistance to influenza is in progress. This study has presented new possibilities of production of influenza virus resistant pig by SCNT for translational research. This work was supported by a grant from Next-Generation BioGreen 21 program (# PJ008121012011), Rural Development Administration, Republic of Korea.

304 THE DEVELOPMENTAL TOXICITY EVALUATION OF 5-FLUOROURACIL AND INDOMETHACIN IN HUMAN EMBRYONIC STEM CELLS

Embryonic stem cells have pluripotency and differentiate into and constitute the cells and tissues of our body. In this study, using human embryonic stem cells (hESC), we evaluated novel methods for screening toxicological chemicals during developmental process. We elucidated developmental toxicity of two well-known chemicals, 5-fluorouracil (5-FU) and indomethacin (Indo) in hESC. The undifferentiated hESC were treated with the chemicals (10–4 to 104 µM of 5-FU and Indo) in a dose-dependent manner during 1 to 3 days. Surface markers (SSEA-4, TRA-1-60, and TRA-1-81) expressed only in undifferentiated hESC were monitored by immunocytochemistry to ensure the characterisation of undifferentiated hESC. Moreover, expression of embryonic stem cell-specific genes was assessed with real-time PCR after treatment of 5-FU and Indo (10–2, 100, and102 µM of 5-FU and Indo). The expression of surface markers was not significantly affected by treatment of 5-FU and Indo. The expression of transcription factors (Oct-4, Sox-2, Nanog, and hTERT) was significantly decreased by high concentrations of 5-FU and Indo (102 µM). However, no difference was observed in treatment of low concentration of 5-FU and Indo (10–2 µM). Taken together, these results suggest that 5-FU and Indo have cytotoxic effects, and modulate the expression of transcription factors that have pivotal roles in undifferentiated hESC. Therefore, we suggest that hESC may have potential to test toxicity of chemicals during embryonic developmental stage.

Sonoelastography can be used to monitor the restoration of Achilles tendon elasticity after injury

PURPOSE

The aim of the current study was to evaluate an ultrasound approach for depicting elastic recovery after stem cell application on injured Achilles tendons.

MATERIALS AND METHODS

A rabbit Achilles tendon injury model was used and randomized hind limbs received an extracellular matrix either with autologous mesenchymal stem cells (group 2, n = 6) or without (group 3, n = 6). The cells were harvested from the rabbits' nuchal fat body. Untreated Achilles tendons (group 1, n = 6) served as controls. Specimens were harvested after 8 weeks and analyzed longitudinally for elasticity using a high resolution 6-15 MHz matrix linear probe. For each tendon, real-time color-coded sonoelastography sequences were recorded for 20 seconds and 10 color histogram frames were obtained. Defined regions of interest (ROIs) were placed on the injury (n = 3) and on the adjacent uninjured tendon tissue (n = 3). In total, 180 measurements were obtained for semi-quantitative analysis.

RESULTS

Repeated measures ANOVA demonstrated a higher elasticity for the stem cell-seeded matrix (group 2) in comparison to the unseeded matrix (group 3) (p < 0.001). No significant difference was found between the injured tendon tissue treated with stem cell-seeded matrix (group 2) and the uninjured Achilles tendons (group 1) (p > 0.05). Moreover, no differences were found between the measurements at different points in time (p > 0.05).

CONCLUSION

Our results indicate that autologous mesenchymal stem cell application successfully restores the mechanical properties of injured tendon tissue. Furthermore, sonoelastography makes it possible to monitor the elasticity of injured Achilles tendons.

Additional effects of bisphenol A and paraben on the induction of calbindin-D(9K) and progesterone receptor via an estrogen receptor pathway in rat pituitary GH3 cells

There are concerns about the combined estrogenic effects of chemicals since mixtures of these chemicals exist in our environment. This study investigated potential additional interactions between bisphenol A (BPA) and isobutylparaben (IBP), which are major xenoestrogens used in the manufacture of plastics, cosmetics, drugs, and other products. The combined effects of these two chemicals were analyzed by measuring the expression of calbindin-D(9k) (CaBP-9k) in rat pituitary cancer GH3 cells. GH3 cells were treated with single and combination doses of both chemicals (BPA single doses: 10(-7), 10(-6) and 10(-5) M; IBP single doses: 10(-7), 10(-6) and 10(-5) M, and each of the BPA and IBP doses combined). Prior to treatment, cells were temporarily transfected with a plasmid containing an ERE-luciferase reporter gene. Luciferase activity was measured as an indicator of ER activation by 17β-estradiol (E2), BPA, and IBP. BPA (10(-5) M) combined with IBP (10(-7) M and 10(-6) M) induced a significant increase in the luciferase activity. Twenty-four hours after treatment, dose-dependent effects were observed in both single and combined dose groups, and several combination doses induced significant increases in the expression of CaBP-9k and progesterone receptor (PR) at both transcriptional and translational levels. Pre-treatment with ICI 182,780, a pure estrogen antagonist, significantly reversed BPA- and IBP-induced CaBP-9k and PR upregulation in GH3 cells. Taken together, these results indicate that BPA and IBP may have additionally increased estrogenic potency via an estrogen receptor-mediated pathway.

Contrast enhanced ultrasound (CEUS) and time intensity curve (TIC) analysis in compartment syndrome: first results

OBJECTIVE

Purpose of this study was to monitor changes of microcirculation in acute compartment syndrome using contrast enhanced ultrasound (CEUS) and to assess the modified perfusion with a special quantification software.

METHODS

8 patients with trauma of the lower limb or the upper extremity were enrolled after acute compartment syndrome was diagnosed clinically and by intracompartmental pressure measurement. The qualitative analysis of the corresponding compartment was assessed using B-scan mode and CEUS simultaneously. CEUS was performed using a multifrequence probe (6-9 MHz, LOGIQ E9 GE) after a i.v. bolus injection of 2 × 2.4 ml contrast agent (SonoVue(®), Bracco, Italy). Digital raw data were stored as cine loops up to 2 minutes. Retrospectively semiquantitative perfusion analysis was performed using time intensity curve analysis and the quantification software QONTRAST(®).

RESULTS

6 out of 8 patients had to be operated due to clinical symptoms and to a pressure perfusion gradient lower than 30 mm Hg. 2 out of 8 were treated conservatively. In all patients haematomas were seen in B-scan mode. No necrosis could be detected. In the TIC analysis low levels of time to peak (20.0 ± 12.1) and area under the curve (118.4 ± 87.8) were observed in acute compartment syndrome. Similarly results have been obtained using the perfusions parameter PEAK (11.1 ± 5.7), time to PEAK (14.7 ± 9.7), regional blood volume (257.1 ± 192.6), and regional blood flow (12.1 ± 6.5) in QONTRAST(®) perfusion software.

CONCLUSION

CEUS may be capable of differing between acute compartment syndrome and imminent compartment syndrome.

Bedside diagnosis of pleural effusion with a latest generation hand-carried ultrasound device in intensive care patients

BACKGROUND

Further development established hand-carried ultrasound (HCU) imagers in daily clinical workflow providing several advantages such as fast bedside availability and prompt diagnosis.

PURPOSE

To evaluate the diagnostic yield of a latest generation HCU imager compared to chest radiography (CR) for the detection of pleural effusion (PE) in intensive care patients.

MATERIAL AND METHODS

Forty-eight hemithoraces of 24 patients on surgical intensive care units were enrolled in this study. All hemithoraces were evaluated using both HCU and CR. Definite diagnosis of PE was achieved using a high-end ultrasound system as standard of reference. Statistical analysis was performed using 2 × 2 tables and a McNemar test. A P value of <0.05 was considered statistically significant.

RESULTS

PE was present in 35 of 48 hemithoraces (73%). The HCU examination was carried out technically successfully in all hemithoraces. Sensitivity and specificity of HCU for the diagnosis of PE was 91% and 100%, respectively, whereas sensitivity and specificity of CR was 74% and 31%, respectively. The difference between HCU and CR was statistically significant with respect to specificity but not sensitivity (P = 0.008 and P = 0.11, respectively).

CONCLUSION

Due to its ease of use and its high diagnostic yield HCU systems of the latest generation constitute a helpful technique for the primary assessment of PE.

Contrast-enhanced ultrasound for differential diagnosis of suspected GvHD in patients after allogeneic transplantation

GvHD is a serious complication in patients after allo-SCT, presenting with unspecific symptoms such as abdominal pain or cramps and diarrhea. Early diagnosis of GvHD, after differentiation from other causes leading to the same symptoms, such as viral or bacterial enteritis, is highly important because the time needed for diagnosing GvHD is directly correlated to a worsening of the outcome. We examined 23 patients presenting with the abdominal symptoms mentioned above, of whom 20 had received an allo-SCT in their history and were thus potential candidates for enteric GvHD. The other three patients were included because they also presented with abdominal symptoms similar to those of GvHD, which could be ruled out due to their history. We wanted to evaluate CEUS in these patients as an additional subgroup to gain more data on the value of CEUS in early detection of enteral GvHD and in the differentiation of GvHD against other causes of abdominal discomfort. All patients underwent CEUS with particular attention to penetration of the intravenously applied microbubbles in the bowel lumen. In the patients having allo-SCT in their history we strove to achieve histological confirmation of GvHD of the GI-tract. The resulting examinations were documented digitally. Out of 17 patients with confirmed GvHD of the GI tract, 14 showed penetration of the intravenously applied microbubbles into the bowel lumen, leading to a sensitivity and specificity of 82% and 100% for transmural bubble penetration for GvHD of the GI-Tract, since the patients without GvHD of the GI tract showed no transmural bubble penetration. In patients with viral or bacterial infections of the GI tract, no transmural penetration of the microbubbles into the bowel lumen was observed. For microbubble penetration as a criterion for GvHD of the GI-Tract, this leads to a negative predictive value (NPV) of 67%, and a positive predicative value (PPV) of 100%.