Nodules Identified on Surveillance Ultrasound for HCC: CEUS or MRI as the Initial Test?

OBJECTIVES

Following positive surveillance ultrasound (US), magnetic resonance imaging (MRI) is recommended for further characterization. We propose contrast-enhanced ultrasound (CEUS) shows equivalent efficacy.

METHODS

This prospective institutional review board approved study recruited 195 consecutive at-risk patients with a positive surveillance US. All had CEUS and MRI. Biopsy (n = 44) and follow-up are gold standard. MRI and CEUS results are classified according to liver imaging reporting and data system (LI-RADS) and patient outcome.

RESULTS

As an US-based modality, CEUS is superior in confirming findings from surveillance US, correlation in 189/195 (97%) on CEUS compared to 153/195 (79%) on MRI. Within these negative MRI examinations, there are 2 hepatocellular carcinoma (HCC) and 1 cholangiocarcinoma (iCCA) diagnosed on CEUS and proven by biopsy. From 195 patients, there are 71 malignant diagnoses from all sources, including 58 LR-5 (45 on MRI and 54 on CEUS) and 13 others, including HCC outside of LR-5 category, and LR-M with biopsy proven iCCA (3 on MRI and 6 on CEUS). CEUS and MRI show concordant results in the majority of patients (146/195, 75%), including 57/146 malignant and 89/146 benign diagnoses. There are 41/57 concordant LR-5 and 6/57 concordant LR-M. When CEUS and MRI are discordant, CEUS upgraded 20 (10 biopsy-proven) from MRI LR-3/4 to CEUS LR-5 or LR-M by showing washout (WO) that MRI failed to show. Additionally, CEUS characterized time and intensity of WO and diagnosed 13/20 LR-5 by showing late and weak WO and 7 LR-M by showing fast and marked WO. CEUS is 81% sensitive and 92% specific in diagnosing malignancy. MRI is 64% sensitive and 93% specific.

CONCLUSIONS

CEUS performance is at least equivalent if not superior to MRI for initial evaluation of lesions from surveillance US.

A107 VISCERAL ADIPOSE TISSUE VOLUME DIFFERENTIATES BETWEEN FIBROSTENOTIC AND INFLAMMATORY CROHN’S DISEASE

Background

Creeping fat, a form of visceral adipose tissue (VAT) that wraps the intestinal wall, influences the formation of Crohn’s disease (CD) strictures. The degree of fat wrapping from intestinal stricture resections is correlated with the extent of chronic inflammation, fibrosis, stricture formation, and response to biologic therapy. VAT and subcutaneous adipose tissue (SAT) ratios from CTE (computed tomography) scans are elevated in CD strictures. However, the definition of strictures in these studies has been poorly defined and not included current well-recognized criteria: 1) bowel wall thickness (BWT), 2) narrowed luminal diameter, and 3) pre-stenotic dilation. (PSD).

Purpose

The objective of this pilot study was to assess the relationship of 2D and 3D VAT:SAT ratios with CT stricture parameters in patients with terminal ileal (TI) CD strictures.

Method

2D VAT:SAT ratios from CT’s of CD patients with TI strictures defined as increased BWT, narrowed luminal diameter (< 50% relative to normal adjacent distended loop), and PSD greater than the stricture diameter were retrospectively obtained from a database and chart review. CT’s from fibrostenotic CD patients were sex and BMI matched to patients with only TI inflammatory behaviour. Patient demographics, medication, smoking, and surgical history were also obtained. Analyses were adjusted for age, sex, and BMI covariates. Unpaired t-tests and multi-variable logistic regression analyses were conducted.

Result(s)

Twenty-eight patients with stricturing CD had a significantly greater mean VAT:SAT volume ratio than 29 non-stricturing CD (41.5 cm³ vs 34.2 cm³, p=0.03). Thirty-six percent (10/28) of CD stricture patients had prior ileocolic resection with a mean disease duration of 13.5 years (range 0-48). The median ileal BWT (7.0 mm, range 4.0-13.0 mm) for the stricturing group was significantly greater than those with inflammatory behaviour (BWT 2.0 mm, p<0.0001). The median luminal diameter and PSD for the stricture group was 2.0 mm (range 0 - 14.0 mm), and 3.0 cm (range 1.0 - 7.3 cm), respectively.

Image

Conclusion(s)

Fibrostenotic TI CD patients have increased VAT:SAT ratios in comparison to those with only inflammatory behaviour. These pilot VAT:SAT results provide an initial foundation for further studies to assess its predictive role in responsiveness of medical or surgical therapies in stricturing CD.

Please acknowledge all funding agencies by checking the applicable boxes below

None

Disclosure of Interest

None Declared

Risk stratification of patients with nonalcoholic fatty liver disease using a case identification pathway in primary care: a cross-sectional study

BACKGROUND

Identification of patients with nonalcoholic fatty liver disease (NAFLD) with advanced liver fibrosis in primary care remains an unmet need. Our primary objective was to implement a pathway driven by shear wave elastography (SWE) to facilitate risk stratification of patients with NAFLD within primary care and evaluate whether SWE assessment can reduce referrals of patients with NAFLD at low risk for fibrosis to hepatology.

METHODS

A multidisciplinary NAFLD clinical care pathway was codeveloped by hepatologists, radiologists and primary care physicians in Calgary to provide access to SWE-based screening of patients with NAFLD risk factors in primary care. The study outcome measures were estimated NAFLD-related referrals to the hepatology service in Calgary after implementation of the NAFLD pathway and characteristics of patients with NAFLD at risk for advanced fibrosis. The NAFLD pathway was implemented in January 2018 and was made available to all primary care physicians in the Calgary Health Zone. Patients with NAFLD who had liver stiffness (SWE value ≥ 8.0 kPa) or an inconclusive assessment were referred to hepatology. A serum liver fibrosis score was also measured with the fibrosis-4 (FIB-4) index, and performance of an FIB-4 index score of 1.30 or greater to risk stratify patients with NAFLD was evaluated. Demographic, clinical and laboratory characteristics of study groups were compared.

RESULTS

Between March and October 2018, 2084 patients with suspected NAFLD were evaluated. Nonalcoholic fatty liver disease was confirmed by ultrasonography in 1958 (94.1%). A majority of the cohort had elevated liver enzyme values (1028 [52.5%]) and obesity (body mass index ≥ 30) (1063/1764 [60.3%]). Most patients with NAFLD (1791 [91.5%]) had an SWE value less than 8.0 kPa and were not referred to hepatology. Sixty-seven patients (3.4%) had an SWE value of 8.0 kPa or more, and 100 (5.1%) had an inconclusive SWE; these patients were referred to hepatology. Using an FIB-4 index score cut-off of 1.30 would have led to hepatology referral of 396/1251 patients (31.6%).

INTERPRETATION

Implementation of a primary care-accessible SWE pathway for patients with NAFLD facilitated fibrosis risk stratification and greatly reduced hepatology referrals. Using the FIB-4 index score alone would led to higher rates of referral of patients with NAFLD.

Resolution of indeterminate MRI with CEUS in patients at high risk for hepatocellular carcinoma

PURPOSE

To show the contribution of CEUS to characterization of indeterminate MRI observations in high-risk patients for hepatocellular carcinoma (HCC).

METHODS

From July to December 2015, 42 consecutive patients referred to CEUS with indeterminate MRI scans comprise our study cohort. There are 50 indeterminate nodule-like observations and 10 arterial phase hyperenhancing foci, suggesting pseudolesions/arterio-portal shunts. MRI and CEUS lesions are classified according to their enhancement features in all phases and Liver Imaging and Reporting Data System (LI-RADS) in a blind read format. Clinical pathologic correlation and 24 months follow-up are performed.

RESULTS

A majority, 37/50 (74%), of indeterminate nodule-like observations have arterial phase enhancement without washout on MRI. CEUS further characterizes enhancement and shows washout in 14/37 (38%). In total, CEUS diagnoses 16 malignant lesions in 14 patients including 14 HCC and 2 ICC. 12/16 (75%) malignant lesions are confirmed by biopsy or follow-up. Ultrasound identification of a nodule differentiates real nodules from pseudolesions. Of the ten suspected arterial-portal shunts on MRI, two show a real nodule on ultrasound, confirmed as an HCC and a regenerative nodule. 15/42 (36%) patients have LI-RADS escalated from LR-3 or 4 on MRI to LR-4 or 5 on CEUS. Overall, the sensitivity of CEUS is (13/16) 81.3% and specificity is (37/37) 100% for malignant diagnosis.

CONCLUSION

Grayscale ultrasound detects true nodules. Dynamic CEUS detects and characterizes washout, correctly predicting HCC. CEUS is complimentary to MRI and can serve as a problem-solving tool when MRI is indeterminate.

Intravenous and Oral Contrast vs Intravenous Contrast Alone Computed Tomography for the Visualization of Appendix and Diagnosis of Appendicitis in Adult Emergency Department Patients

Purpose

The study sought to compare radiologist's ability to 1) visualize the appendix; 2) diagnose acute appendicitis; and 3) diagnose alternative pathologies responsible for acute abdominal pain among adult patients undergoing computed tomography (CT) scan with 3 different protocols: 1) intravenous (IV) contrast only; 2) IV and oral contrast with 1-hour transit time; and 3) IV and oral contrast with 3-hour transit time.

Methods

We collected data of 225 patients; 75 consecutive patients with a clinical suspicion of appendicitis received oral contrast for 3 hours and IV contrast, 75 received oral contrast for 1 hour and IV contrast, and 75 trauma patients received IV contrast only. Three independent reviewers, blinded to final pathology, retrospectively analysed the cases and documented visualization of the appendix, periappendiceal structures, and their confidence in diagnosing appendicitis. Clinical diagnoses were derived from a combination of clinical, surgical, pathologic, or radiologic follow-up.

Results

Frequency of visualizing the appendix within IV group alone was 87.3%, IV with oral for 1 hour was 94.1%, and IV with oral for 3 hours was 93.8%. Both oral contrast groups had 100% sensitivity and negative predictive value in diagnosis of acute appendicitis. Specificity for the 1- and 3-hour oral contrast groups was 94.1% and 96.1%, respectively and positive predictive value for both groups was 92%.

Conclusions

Our findings suggest that reader confidence in visualizing the appendix improved with addition of oral contrast as compared to IV contrast alone. One- and 3-hour oral regimens have a similar diagnostic performance in diagnosing appendicitis.

Validity of the diagnostic criteria for chronic cerebrospinal venous insufficiency and association with multiple sclerosis

BACKGROUND

The chronic cerebrospinal venous insufficiency theory proposes that altered cerebral venous hemodynamics play a role in the pathophysiology of multiple sclerosis. We aimed to explore the validity of this hypothesis by assessing the diagnostic criteria for chronic cerebrospinal venous insufficiency in persons with and without multiple sclerosis.

METHODS

We compared the proportion of venous outflow abnormalities between patients with multiple sclerosis and healthy controls using extracranial Doppler ultrasonography and gadolinium-enhanced magnetic resonance venography. Interpreting radiologists were blinded to the clinical status of participants.

RESULTS

We enrolled 120 patients with multiple sclerosis and 60 healthy controls. High proportions of both patients (67/115 [58%]) and controls (38/60 [63%]) met 1 or more of the proposed ultrasound criteria for diagnosis of chronic cerebrospinal venous insufficiency (p = 0.6). A minority of patients (23/115 [20%]) and controls (6/60 [10%]) fulfilled 2 or more of the proposed criteria (p = 0.1). There were no differences between patients and controls in the prevalence of each individual ultrasound criterion. Similarly, there were no differences in intracranial or extracranial venous patency between groups, as measured by magnetic resonance venography.

INTERPRETATION

We detected no differences in the proportion of venous outflow abnormalities between patients with multiple sclerosis and healthy controls. Moreover, our study revealed significant methodologic concerns regarding the proposed diagnostic criteria for chronic cerebrospinal venous insufficiency that challenge their validity.

Anchor placement and subsequent movement in a mesh kit with self-fixating tips: 6-month follow-up of a prospective cohort

OBJECTIVE

To describe the initial placement of Elevate single-incision mesh kit device tips relative to the sacrospinous ligament, and to measure tip movement over a 6-month period from initial placement.

DESIGN

Prospective cohort.

SETTING

Tertiary care urogynaecology centre in Calgary, Canada.

POPULATION

Women electing for surgical management of anterior vaginal wall prolapse.

METHODS

Ten women underwent anterior prolapse repair using the Elevate single-incision mesh kit with a metallic fiducial marker attached to the tips of the surgical device. Women were imaged by magnetic resonance imaging (MRI) within 48 hours of surgery, and again 6 months later to investigate the position of the device tips and change ≥4 mm over the 6-month postoperative period.

MAIN OUTCOME MEASURE(S)

Position of self-fixating tips within 48 hours of surgery, and at six months post-operative.

RESULTS

Anchor insertion was directly into the sacrospinous ligament in 10 of 20 insertion points (50%, 95% CI 27-73%). Movement was most often noted in the cranial-caudal direction: a change in location of ≥4 mm was observed for 8/20 anchors (40%, 95% CI 19-64%). Cranial-caudal movement was observed less frequently among sacrospinous anchors than among anchors inserted into other pelvic structures (1/10 versus 7/10, P = 0.020, difference in proportion -60%, 95% CI -94 to -26%). PFDI-20 scores improved statistically significantly by 6 months (P = 0.008, mean change -62.9%, 95% CI -105.1 to -20.7%), but PFIQ-7 scores did not change statistically significantly over the same time period (P = 0.523, mean change -12.4%, 95% CI -54.5 to 29.8%).

CONCLUSIONS

The novel self-fixating anchoring tips of this single-incision mesh kit do not reliably anchor into the sacrospinous ligament. The tips have been shown to move with time, although not all cases of anchor movement were associated with recurrent prolapse.

A multicenter review of deep venous thrombosis prophylaxis practice patterns for blunt hepatic trauma

BACKGROUND

Non-operative management of blunt hepatic trauma is successful in the majority of hemodynamically stable patients. Due to the risk of recurrent hemorrhage, pharmacologic deep venous thrombosis (DVT) prophylaxis is often delayed. The optimal timing of prophylaxis is unclear. A multi-centre, retrospective review of patients with blunt hepatic injuries presenting between 2000 and 2004 was performed. All patients had an ISS >/= 12 and a CT scan confirming hepatic trauma. Patients were categorized into: (1) early DVT prophylaxis (</= 48 hrs of admission), (2) delayed prophylaxis (>48 hrs), and (3) no prophylaxis.

METHODS AND RESULTS

Thirty-seven (25%) and 45 (42%) patients received early and delayed DVT prophylaxis respectively. The remainder (32%) received none. Mean hepatic injury grades were lower in the early prophylaxis group (II) compared to the delayed and no prophylaxis cohorts (III)(p = 0.002). The number of patients requiring post-admission blood transfusions was highest in the delayed group (44%) compared to the early (26%) and no prophylaxis (6%) groups (p = 0.03). No patient in the early prophylaxis cohort developed a DVT or required delayed angiographic or operative intervention. Two patients in the delayed group failed non-operative management. Eight (18%) patients in the delayed group developed a clinically significant DVT; 1 (2%) progressed to a PE.

CONCLUSION

Practice patterns indicate that chemical DVT prophylaxis initiated within 48 hours of admission may be safe in patients with significant blunt hepatic trauma. Delays in prevention result in venothromboembolic events, but not in fewer blood transfusions or a decreased need for subsequent angiographic or operative therapies.

The spectrum of ulnar collateral ligament injuries as viewed on magnetic resonance imaging of the metacarpophalangeal joint of the thumb

OBJECTIVE

To elucidate the spectrum of ulnar collateral ligament (UCL) injuries detectable by magnetic resonance imaging (MRI).

METHODS

Twenty-one patients (12 male and 9 female, aged 14-62 years) with acute hyperabduction injuries of the first metacarpophalangeal joint underwent MRI for clinically suspected UCL injuries. All scans were performed in either a large-bore, 1.5-T imager or an experimental small-bore, 1.9-T imager. MRI findings and clinical evaluations of all patients and surgical reports of those who underwent surgery (n = 10) were reviewed and correlated retrospectively.

RESULTS

A total of 6 patients demonstrated injuries that did not fall into previously described categories of UCL injuries and therefore illustrated the existence of a subclass of UCL injuries. We divided the MRI findings into 5 categories: Stener's lesions (n = 6), moderately displaced (> or = 3 mm) complete tears (n = 5), minimally displaced (< 3 mm) complete tears (n = 4), nondisplaced complete tears (n = 3) and partial tears (n = 3). None of the MRI scans demonstrated a normal UCL. Although sensitivity and specificity were not calculated, only 2 cases demonstrated discordance between the MRI results and surgical findings or clinical outcomes.

CONCLUSION

There is a spectrum of UCL injuries that have not previously been described.