CT Patterns of Interstitial Lung Disease in Patients with Plaque Psoriasis: A Retrospective Case Series Study

Background and Objectives: Recently published articles reported an association between psoriasis and interstitial lung diseases (ILDs). The aim of this study is to evaluate the differences in ILD computed tomography (CT) patterns between smoker and never smoker plaque psoriasis (PP) patients under topical treatment without psoriatic arthritis (PA), inflammatory bowel disease (IBD) or connective tissue diseases (CTDs). Matherials and Methods: Two radiologists evaluated chest CT examinations of 65 patients (33 smokers, 32 never smokers) with PP. Results: Usual interstitial pneumonia (UIP) pattern was diagnosed in 36 patients, nonspecific interstitial pneumonia pattern in 19, hypersensitivity pneumonitis in 7 and pleuropulmonary fibroelastosis (PPFE) in 3 patients. UIP pattern showed a statistically significant higher frequency in smoker patients (p = 0.0351). Respiratory symptoms were reported in 80% of patients. Conclusions: ILDs seems to represent a new comorbidity associated with psoriasis. Moreover, a statistically significant association between smokers and UIP pattern in PP patients is found. Respiratory symptoms should be evaluated in PP patients, in collaboration with a radiologist and a pneumologist. However, further studies are required to better understand the epidemiology of ILDs in PP patients.

Invasive ductal carcinoma mammographic findings: Correlation with age, breast composition and tumor size

BACKGROUND/OBJECTIVE

The aim of this study was to identify the mammographic findings associated with malignancy in different age groups, taking into account breast composition (BC) and lesion size.

METHODS

Preoperative mammograms of 1023 invasive ductal carcinomas were retrospectively evaluated. According to the American College of Radiology Breast Imaging Reporting and Data System, cancer mammographic findings were classified as mass, calcifications, architectural distortion and asymmetry, and breasts were assessed as non-dense (A or B BC) and dense (C or D BC). Patient cohort was subdivided into three age groups (group 1: <50 years of age; group 2: between 50 and 69; group 3: ≥70 years of age).

RESULTS

Significant results of multinomial logistic regression were the association between mass and non-dense breast (p < 0.0001) and the association between mass and tumor size larger than 15 mm (p = 0.0049).

CONCLUSIONS

Mass finding of invasive ductal breast carcinoma is associated with breast composition and tumor size.

Low diffusion level within a fibroadenoma as the sole sign of ductal carcinoma in situ: A case report

We present a case of ductal carcinoma in situ within a fibroadenoma. Breast cancer arising within fibroadenoma incidence ranges from 0.125% to 0.02%, and ductal carcinoma in situ is not the most frequent malignancy that can be found within a fibroadenoma. Dynamic contrast-enhanced magnetic resonance imaging showed an oval mass with circumscribed margins and dark internal septations, suspicious for fibroadenoma. According to European Society of Breast Radiology diffusion-weighted imaging consensus, mean apparent diffusion coefficient value obtained by drawing a small region of interest on the lesion apparent diffusion coefficient map showed a low diffusion level. Therefore, ductal carcinoma in situ within a fibroadenoma was diagnosed at final pathology after surgical excision.

Ultra-low-dose chest CT in adult patients with cystic fibrosis using a third-generation dual-source CT scanner

INTRODUCTION

Chest computed tomography (CT) examinations are performed routinely in some cystic fibrosis (CF) centers in order to evaluate lung disease progression in CF patients. Continuous CT technological advancement in theory could allows a lower radiation exposure of CF patients during chest CT examinations without an image quality reduction, and this could become increasingly important over time in order to reduce the cumulative radiation dose effects given the continuous increase of CF patients predicted median survival.

OBJECTIVE

The aim of this study was to compare objective and subjective image quality and radiation dose between low-dose chest CT examinations performed in adult CF patients using a third-generation DSCT scanner and a 64-slices single-source CT (SSCT) scanner.

MATERIALS AND METHODS

Between January 2016 and August 2019, 81 CF patients underwent low-dose chest CT examinations using both a 64-slices SSCT scanner (2016-2017) and a third-generation DSCT scanner (2018-2019). Objective image noise standard deviation (INSD), signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), overall subjective image quality (OSIQ), subjective image noise (SIN), subjective evaluation of streaking artifacts (SA), movement artifacts (MA) and edge resolution (ER), dose-length product (DLP), volume computed tomography dose index (CTDIvol) and effective radiation dose (ERD) were compared between DSCT and SSCT examinations. DSCT examinations consisted in spiral inspiratory end expiratory acquisitions. SSCT examinations consisted in spiral inspiratory acquisitions and five axial expiratory ones.

RESULTS

DSCT protocol showed statistically significant lower spiral inspiratory phase mean DLP, CTDIvol and ERD than SSCT protocol, with a 25% DLP, CTDIvol and ERD reduction. DSCT protocol showed statistically significant higher overall (inspiratory and expiratory phases) mean DLP, CTDIvol and ERD than SSCT protocol, with a 40% DLP, CTDIvol and ERD increase. Objective image quality (INSD, SNR and CNR) and SIN differences were not statistically significant, but subjective evaluation of DSCT images showed statistically significant better OSIQ and ER, as well as statistically significant lower SA and MA with respect to SSCT images.

CONCLUSIONS

To our knowledge, this is the first study evaluating chest CT image quality and radiation dose in adult CF patients using a third-generation DSCT scanner, and it showed that technological advancements could be used in order to reduce radiation exposure of volumetric examinations. The spiral inspiratory dose reduction can be obtained with concomitant improvements in subjective image quality with comparable objective quality. This will probably allow a wider use of this imaging modality in order to assess bronchiectasis and will probably foster spiral expiratory acquisition for small airways disease evaluation.

Contrast-enhanced ultrasound evaluation of testicular syphilis: a case report

In North America and Europe, syphilis incidence has increased dramatically in the past decade among high-risk groups. Syphilis may occur in any organ, including the testis. There are not many cases of testicular syphilis assessed by means ofultrasound examination described in the literature, and in no case was the evaluation carried out using advanced ultrasound techniques. Here we present a case of testicular syphilis evaluated by contrast-enhanced ultrasound.

Apparent diffusion coefficient value in breast papillary lesions without atypia at core needle biopsy

PURPOSE

The main aim of the study was to assess if the mean apparent diffusion coefficient (ADC) value was significantly different between papillary lesions (PL) without atypia and PLs with atypical or malignant foci. A secondary objective was to evaluate if patients mean age, MRI BI-RADS® descriptors and assessment category were significantly different between these two PL groups.

METHODS

In this eight year retrospective study were included 122 patients (mean age, 51 years; range, 24-78) with 122 PLs without atypia at micro-histological examination after core needle biopsy (CNB) performed under sonographic guidance. All patients underwent surgical excision biopsy within 3 months after CNB. All patients underwent MRI examination before surgical excision, including STIR, DWI and Dynamic Contrast-Enhanced sequences.

RESULTS

Mean ADC value difference between PLs without and with atypia or malignant foci was statistically significant (p < 0.0001). Mean ADC value optimal threshold in order to distinguish the two groups was 1.418 × 10^-3 mm²/s. A mean ADC value ≤ 1.418 × 10^-3 mm²/s could predict atypical or malignant foci within a PL with 83.9% sensitivity and 75.8% specificity. No statistically significant difference was found with regard to patients mean age, MRI BI-RADS® descriptors and assessment category between these two PL groups.

CONCLUSIONS

Mean ADC value of PLs without atypia at CNB is an efficient tool in order to help distinguish between PLs without and with atypical or malignant foci at final pathology on surgical excision, and it could be used to help decide how to manage these lesions.

Diagnostic detection with cardiac tomography and resonance of extremely rare coronary anomaly: A case report and review of literature

BACKGROUND

The association of two congenital coronary artery anomalies (CAAs) is extremely rare but represents one of the main cause of sudden cardiac death in young athletes. Although coronary angiography (CX-A) is still widely used in childhood, cardiac magnetic resonance (C-MRI) and cardiac computed tomography (C-CT) have recently taken on an increasing diagnostic role in early detection of CAAs and concomitant congenital cardiac malformations.

CASE SUMMARY

A healthy 10-year-old male patient was referred to the Radiological Department of our Institution due to no evidence of left coronary artery in echocardiographic examination. With C-MRI was detected marked myocardial trabeculation and was suspected anomalous origin and course of left circumflex (LCx) artery and of left anterior descending (LAD) artery. With third generation Dual Source C-CT 192x2-sections (SOMATOM Force, Siemens, Germany) was confirmed anomalous origin of LCx artery from right pulmonary artery associated with anomalous origin of LAD artery from right coronary artery with course in front of right ventricular outflow tract. The patient underwent surgical treatment with reimplantation of the anomalous LCX and LAD arteries into the wall of ascending aorta, with no postoperative complications. The patient remained asymptomatic and follow-up C-MRI scan four months after operation showed complete success of surgery treatment.

CONCLUSION

This case highlights the diagnostic potential of C-CT and C-MRI in evaluation of CAAs and of cardiac morphology and functionality, with very low radiation dose and without the risks related to invasive procedure.

Contrast-enhanced ultrasound performance in predicting blunt splenic injuries requiring only observation and monitoring

AIMS

To assess contrast enhanced ultrasound (CEUS) performance in the prediction of non-operatively managed blunt spleen injuries requiring only observation and monitoring during follow-up and to evaluate if CEUS accuracy was higher than conventional ultrasound (US) in this field.

MATERIAL AND METHODS

In 112 hemodynamic stable blunt spleen trauma patients, CEUS was performed for follow-up after computed tomography evaluation in the emergency department. CEUS and US performance were assessed considering as true negative cases patients that had not underwent interventional or surgical treatment during follow-up and were assessed as negative for splenic complications respectively by CEUS or US examinations.

RESULTS

 CEUS showed sensitivity of 100%, specificity of 96.1%, positive predictive value of 69.2%, negative predictive value of 100.0% and accuracy of 96.4%. CEUS showed a significantly higher accuracy than conventional US (p=0.013).

CONCLUSIONS

 CEUS is a very useful imaging modality during follow-up of blunt splenic trauma non-operatively managed, allowing an efficientprediction of splenic injuries requiring only observation and monitoring during follow-up.

Rupture of the cavernous body diagnosed by contrast-enhanced ultrasound: Presentation of a clinical case

Penile trauma represents a urological emergency characterized by the breaking of the albuginea tunic. A fast diagnosis and early surgical repair are the best treatments to avoid post-operative sequelae such as curvatures or deformities of the penis. An ultrasound evaluation may not be able to identify the injury in the tunica albuginea due to the edematous swelling of the penis and clots within the tear deteriorate the image contrast and can hide the injury. We here report a case study of successful management via surgical treatment for rupture of the cavernous body diagnosed by contrast-enhanced ultrasound in a young patient with penile trauma.

Role of DCE-MR in predicting breast cancer subtypes

OBJECTIVE

The purpose of this retrospective study is to find a correlation between dynamic contrast-enhanced MR features with histological, immunohistochemical and loco-regional characteristics of breast cancer.

MATERIALS AND METHODS

A total of 149 patients with histopathologically confirmed invasive breast carcinoma underwent MR imaging. Histological analysis included: histological features (histological type, necrosis, vascular invasion and Mib-1), immunohistochemical characterization (immunophenotype, receptor status, HER2-neu and grading) and loco-regional characteristics (T and N). The kinetic MR features analyzed were: curve type, maximum enhancement, time to peak, wash-in and wash-out rate, brevity of enhancement and area under curve.

RESULTS

MRI kinetic parameters and immunohistological features were compared using chi square test, two-tailed student t test and Anova test, with p = 0.05 level of significance. Vascular invasion was shown to be significantly related to time to peak (p = 0.02). The immunohistotype was shown to be significantly related with maximum enhancement (p = 0.05), time to peak (p = 0.04) and wash-in rate (p = 0.01). ER status correlates with maximum and relative enhancement (p = 0.004 and p = 0.028), wash-in rate (p = 0.0018) and area under curve (p = 0.006). PR status was significantly related to time to peak (p = 0.048) and wash-in rate (p = 0.05).

CONCLUSION

Maximum enhancement absolute and relative, time to peak, wash-in rate and area under the curve significantly correlate with several prognostic factors, like ER status, immune profile and tumoral vascular invasion, and may predict the aggressiveness of the tumor.

Morphological MR features and quantitative ADC evaluation in invasive breast cancer: Correlation with prognostic factors

OBJECTIVE

Assess the correlation between MRI characteristics of invasive breast cancer and tumor prognostic features.

MATERIALS AND METHODS

95 women with invasive breast cancer underwent pre-treatment MR. Morphological findings and quantitative ADC were retrospectively evaluated.

RESULTS

Smaller size, round shape, spiculated margins and homogeneous internal enhancement pattern on dynamic MRI were independently associated with established predictors of good prognosis, while larger size and rim enhancement pattern were related to predictors of poor prognosis. A positive correlation was observed between ADC value and clinical stage.

CONCLUSIONS

MRI may be a useful tool for breast cancer aggressiveness prediction and for guiding subsequent clinical-therapeutic management.

Are liver nested stromal epithelial tumors always low aggressive?

Nested stromal-epithelial tumor (NSET) is a non-hepatocytic and non-biliary tumor of the liver consisting of nests of epithelial and spindled cells with associated myofibroblastic stroma and variable intra-lesional calcification and ossification, which represents a very rare and challenging disease. Most of the reported cases have been treated with surgery, obtaining a long survival outcome. Here, we report the case of a 31-year-old Caucasian man who underwent surgery at our institution for a large, lobulated, multinodular mass of the right hemi-liver. The histological exam confirmed the diagnosis of NSET. After 6 mo from surgery, a liver recurrence was described and a chemo-embolization was performed. After a further disease progression, based on the correlation between the histological features of the disease and those of the hepatoblastoma, a similar chemotherapy regimen (with cisplatin and ifosfamide/mesna chemotherapy, omitting doxorubicin due to liver impairment) was administered. However, infection of the biliary catheter required a dose modification of the treatment. No benefit was noted and a progression of disease was radiologically assessed after only four cycles. The worsening of the clinical status prevented further treatments, and the patient died a few months later. This case report documents how the NSET might have an aggressive and non-preventable behavior. No chemotherapy schedules with a proved efficacy are available, and new data are needed to shed light on this rare neoplasm.

Role of Contrast-Enhanced Sonography in the Evaluation of Axillary Lymph Nodes in Breast Carcinoma: A Monocentric Study

OBJECTIVES

To evaluate the diagnostic performance of contrast-enhanced sonography for characterization of the lymph node status (metastatic or not) in patients with breast carcinomas by comparison with sentinel lymph node biopsy.

METHODS

From January to August 2015, 50 female patients with a histologic diagnosis of invasive breast carcinoma were prospectively examined by ipsilateral axillary contrast-enhanced sonography. The test was performed by a single radiologist using an ultrasound system with a broadband 8-12-MHz, 38-mm high-resolution linear transducer. For the target lymph node, we chose a node with a sonographic pattern that was suspicious for malignancy: ie, a longitudinal-to-transverse diameter ratio of less than 2, absence of a central hyperechogenic hilum, or both. In cases with a lack of sonographic signs of malignancy, we evaluated the node with the maximal transverse diameter. Nodes were considered malignant in cases with total absence of contrast enhancement and in those with enhancement alterations. Within 1 week, all patients underwent sentinel lymph node biopsy, followed by a histologic test.

RESULTS

The histologic test showed benignity in 22 of 50 sentinel lymph nodes, whereas 28 were metastatic. Among the 22 patients with negative biopsy results, contrast-enhanced sonography showed 18 concordances and 4 false-positives results; among the 28 with positive biopsy results, contrast-enhanced sonography obtained 100% correct characterizations of the axillary status. The sensitivity, specificity, and accuracy were 100%, 82%, and 92%, respectively.

CONCLUSIONS

Contrast-enhanced sonography appears to be a method with high accuracy for characterization of axillary lymph nodes, very close to the reference-standard sentinel lymph node biopsy. This technique seems to have overall high sensitivity.

Chromium exposure and germinal embryonal carcinoma: first two cases and review of the literature

The aim of the study was to determine the potential role of occupational exposures to chromium (Cr) in the onset of extragonadal germinal embryonal carcinoma. The first two cases of workers in a company with Cr exposure are reported. The published scientific literature regarding the topic in peer-reviewed journals including MEDLINE and CancerLit databases was extensively reviewed. Two young patients who were coworkers in the same company, exposed to Cr, developed extragonadal germinal embryonal carcinomas. One of them also developed angiosarcoma of the mediastinum. To the best of our knowledge these are the first two cases of germinal embryonal carcinoma in patients with occupational exposure to Cr.

Breast cancer and primary systemic therapy. Results of the Consensus Meeting on the recommendations for pathological examination and histological report of breast cancer specimens in the Marche Region

Primary systemic therapy (PST) adds some practical problems to the pathologic examination of neoplastic breast tissue obtained from patients before and after chemotherapy. Pathologists, oncologists, breast surgeons, radiotherapists and radiologists in the Marche Region held a Consensus Meeting in Ancona on May 13, 2010, in which 15 statements dealing with neoadjuvant chemotherapy were approved by all participants. The first two statements are related to the pre-PST phase and concern the technical procedures and the histological report of the core biopsy. The other statements deal with similar issues of the post-PST surgical specimen.

[Atherosclerosis in rheumatoid arthritis: the role of high-resolution B mode ultrasound in the measurement of the arterial intima-media thickness]

BACKGROUND

Patients with rheumatoid arthritis (RA) have a reduced life expectancy and high cardiovascular morbidity and mortality as compared to the general population. A number of possible factors for the atherogenesis in this disease have been described, such as homocysteine, altered serum levels of selected lipoproteins and treatment. Recent findings indicate that the systemic inflammation may contribute to the development of atherosclerosis and confer an additional risk for cardiovascular death among patients with RA. The aim of our study was to evaluate the ability of high resolution Bmode ultrasound and color Doppler to assess the existence of subclinical atherosclerosis in RA patients, measuring the intima-media thickness (IMT) and resistance index of the common carotid arteries.

METHODS

Carotid IMT and carotid plaque were measured using high-resolution B-mode ultrasound in 40 patients with RA and 40 age- and sex-matched healthy persons. We used color Doppler ultrasound to assess vascular damage of the common carotid arteries and the resistance index (RI) was determined by analysis of the spectral waveforms. Serum total cholesterol, triglycerides-density lipoprotein cholesterol, low-density lipoprotein cholesterol, rheumatoid factor, body mass index (BMI), visual analogue scale (VAS) were determined in patients and controls. C-reactive protein (CRP) and the DAS28 were used to measure systemic inflammation.

RESULTS

Common carotid IMT were significantly higher (p=0.0009) in RA patients (0.83 +/- 0.23) compared with controls (0.66 +/- 0.22). In RA patients common carotid IMT was significantly correlated with serum total cholesterol (p=0.0008), low-density lipoprotein cholesterol (p=0.006), triglycerides (p=0.042), age (p=0.031) and disease duration (p=0.019). No significant correlation was found with clinical and laboratory parameters reflecting disease activity. The prevalence of plaques was higher in RA patients compared with controls (25% vs 12.5%). There was no significant difference in color Doppler findings, and in particular in RI, between patients and controls.

CONCLUSIONS

Our results confirm an accelerated atherosclerosis, as shown by increased common carotid IMT, in patients with RA compared with controls and it is related mainly to lipid levels. High-resolution B-mode ultrasound may be considered a promising, sensitive and non invasive tool for assessing the existence of subclinical atherosclerosis in RA patients.

Radiological scoring methods for ankylosing spondylitis: a comparison between the Bath Ankylosing Spondylitis Radiology Index and the modified Stoke Ankylosing Spondylitis Spine Score

OBJECTIVE

The main objective of the present study was to test the interobserver reliability, truth, discrimination and feasibility of two scoring methods available in ankylosing spondylitis (AS) over a follow-up period of 3 years.

METHODS

Two blinded trained observers scored 95 AS radiographs from a cohort of AS patients. Each radiograph was scored by two scoring methods, the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS), and the Bath Ankylosing Spondylitis Radiology Index--spine (BASRI-spine). Interobserver agreement was analyzed by intraclass correlation coefficients (ICC). The construct validity was assessed by examining the correlation of the scoring methods with measures of spinal mobility (Bath Ankylosing Spondylitis Metronomy Index--BASMI), functional limitation (Bath Ankylosing Spondylitis Functional Index--BASFI) and disease duration. Bland and Altman's 95% limits of agreement method and effect size (ES) analysis were used to estimate the smallest detectable difference (SDD) of radiological progression and responsiveness.

RESULTS

The BASRI-spine reached intra- and interobserver ICC of 0.755 and 0.831, respectively. The mSASSS scores were more reliable, with ICC of 0.874 and 0.941, respectively. Both scoring systems correlated significantly with BASMI (p = 0.01), while only the mSASSS showed a significant correlation (p = 0.02) with BASFI. With regards to sensitivity to change, it was found that mSASSS classified the highest percentage of patients with more changes than the BASRI-spine (mSASSS: 35.8% vs. BASRI-spine: 15.8%). The ES analysis also suggested that the mSASSS was more responsive than BASRI-spine. Concerning feasibility, the BASRI-spine takes less time for scoring.

CONCLUSION

We have shown that the mSASSS offers advantages in measurement properties and is the most appropriate method by which to assess progression of structural damage in AS.

[Usefulness of ultrasonography and color Doppler sonography in the diagnosis of major salivary gland diseases]

The algorithm for imaging of the salivary glands depends on the clinical scenario with which the patient presents to the clinician. Ultrasound has been increasingly used in recent years and thanks to high performance, easy to use apparatus, it can now be used for exploration of the salivary glands. This non invasive, painless and relatively inexpensive examination provides rapid visualisation of the salivary glands and is a useful adjunct to computed tomography and magnetic risonance imaging examination, particularly in tumour pathology. In recent years, publications have highlighted the potential uselfulness of salivary gland ultrasonography as a simple and non-invasive adjunctive test for the detection of gland involvement in Sjögren's syndrome (SS). SS is a chronic inflammatory disease of the salivary glands characterised by focal lymphocytic infiltrates that cause progressive destruction of the acinar structures. The findings of a previous study lead us to believe, in agreement with other examiners, that semiquantitative assessment of ultrasonographic images of the salivary glands is a sensitive and very useful means of evaluating salivary involvement in SS. Color Doppler sonography is a recently introduced method which makes it possible to evaluate intra- and perilesional vascularization and to perform a hemodynamic study of the area being explored. The color Doppler sonography can provide a useful adjunct to conventional ultrasound, increasing diagnostic accuracy in submandibular- parotid masses and to analyze physiologic changes that occur during salivary stimulation in normal subjects and the flow alterations that occur in diseased glands of SS patients. This article reviews the normal ultrasound anatomy of the salivary glands along with lithiasic, inflammatory, tumoral, and autoimmune disease such as SS.

Contrast-Enhanced Breast MRI in Patients with Suspicious Microcalcifications on Mammography: Results of a Multicenter Trial

OBJECTIVE

The objective of our study was to test dynamic MRI in evaluating mammographically detected suspicious microcalcifications.

MATERIALS AND METHODS

One hundred twelve patients with mammographically detected microcalcifications with BI-RADS category 5 (n = 78) or 4 (n = 34) lesions were studied at 17 centers a using 3D gradient-echo dynamic coronal technique (< or = 3 mm thickness) and 0.1 mmol/kg of gadoteridol. A pathologic sample was obtained in all cases. Agreement between the major diameter measured on mammography, MRI, or both and the major diameter measured at pathologic examination was calculated in 62 cases.

RESULTS

Of the 112 lesions, pathologic examination revealed 37 benign lesions, 33 ductal carcinoma in situ (DCIS), and 42 invasive carcinomas. The specificity of MRI for benign lesions was 68%. Considering the subgroups of calcifications alone and calcifications associated with masses, the specificity values became 79% and 33%, respectively. The sensitivity of MRI for DCIS was 79%. Analysis of the two subgroups showed sensitivity values of 68% for calcifications alone and of 1% for calcifications associated with masses. The sensitivity for invasive carcinomas was 93%. Analysis of the two subgroups showed sensitivity values to be 92% for calcifications alone and 94% for calcifications associated with masses. Considering the overall results, the sensitivity of MRI was 87%; specificity, 68%; positive predictive value, 84%; negative predictive value, 71%; and accuracy, 80%. Considering the subgroups of calcifications alone and calcifications associated with masses, the sensitivity values became 80% and 97%; the positive predictive values, 86% and 82%; the negative predictive values, 71% and 75% (95% confidence interval [CI], 0.19-0.99); and the accuracy values, 80% and 82% (95% CI, 0.66-0.92), respectively. An odds ratio (OR) of 13.54 (95% CI, 5.20-35.28) showed a raised risk of malignant breast tumor in subjects with positive MR examination of mammographically detected suspicious clusters of microcalcifications. The statistical analysis on each subgroup showed an OR of 15.07 (95% CI, 4.73-48.08) for calcifications alone and an OR of 14.00 (95% CI, 1.23-158.84) for calcifications associated with masses. Any significant improvement in the predictive ability of dynamic MRI depending on the extent of calcifications on mammography was not proved. Considering the 62 cases of proved malignancy with measured maximal diameter at pathologic examination, both mammography and MR examination seem to overestimate tumor extent.

CONCLUSION

The not-perfect sensitivity of MRI (87%), when applying our interpretation criteria and imaging sequences, is a crucial point that prevents us from clinical use of MRI in the diagnosis of mammographically detected microcalcifications.

Perioperative anemia and blood transfusions as prognostic factors in patients undergoing resection for non-small cell lung cancers

We hypothesised that anemia could represent an important prognostic factor and perioperative blood transfusions do not reduce the risk of relapse. In order to explore this topic, we assessed the correlation of preoperative anemia and blood transfusions with survival in patients with resected non-small cell lung cancer (NSCLC). Patients who underwent radical surgery for NSCLC at the Department of Thoracic Surgery of Università Politecnica delle Marche from January 1996 through December 2001, were included in our study. Four hundred and thirty-nine patients were eligible for our analysis. Survival appeared worse in patients with haemoglobin (Hb) < or =10 g/dl versus Hb >10 g/dl (p=0.012). Stratifying patients in three groups on their Hb level (group 1: Hb < or =10 g/dl; group 2: Hb=10-12 g/dl; group 3: Hb > or =12 g/dl), we observed a worse prognosis in patients with lower Hb levels, too (p=0.0325) and also in the transfused population (p=0.046). At multivariate analysis, only the age of patients, pathological stage and Hb levels resulted indicators of prognosis. Our results suggested that anemia could represent an important prognostic factor in resected NSCLC and correction of anemia in the perioperative setting does not reduce the risk of relapse.

Screening US for blunt abdominal trauma: a retrospective study

PURPOSE

To assess the accuracy of screening US in patients with blunt abdominal trauma first admitted in the trauma centre of our general hospital.

MATERIALS AND METHODS

The reports of 864 abdominal US examinations of primary trauma patients (139 with major and 725 with minor injuries) obtained with standard protocols were retrieved. For each case, US reports were reviewed and compared to the best available reference standard. The accuracy of US was assessed by evaluating the method's overall ability to distinguish negative from positive cases by showing at least one of the lesions documented by the reference standard and its specific ability to depict injuries separately and independently.

RESULTS

US exhibited a satisfactory overall ability to distinguish negative from positive patients (91.5% sensibility and 97.5% specificity in major trauma patients vs. 73.3% sensibility and 98.1% specificity in minor trauma patients) and a satisfactory specific ability to depict injuries separately and independently in major trauma patients. Of the 21/864 false negative reports (5 in patients with major and 16 in cases with minor trauma), only one affected patient management, a major trauma case, by delaying an emergency laparotomy.

CONCLUSIONS

Its satisfactory accuracy for major trauma suggests that US could be employed not only to screen cases for emergency laparotomy but also as an alternative to screening CT. However, since major traumatic injuries generally carry an imperative indication for CT, especially as regards neurological, thoracic and skeletal evaluation, US has the not secondary task of performing a prompt preliminary examination using a simplified technique in the emergency room simultaneously with resuscitation.

Hemodynamic effects of a prostacyclin analog (Prostavasin) in systemic scleroderma patients

PURPOSE

We examined the effects of a prostacyclin analogue (Prostavasin) on the circulation of upper extremity, cerebral, ocular and visceral districts such as portal vein, hepatic artery, superior mesenteric artery, and interlobar renal artery in scleroderma patients.

MATERIALS AND METHODS

peripheral vasculature was evaluated by the brachial artery flow-mediated dilatation by the high resolution ultrasound cross-sectional measurement, splenic arterial pulsatility index (PI) resistance index (RI) of the middle cerebral artery, the central retinal artery, the visceral arteries and the portal vein flow were assessed by colour Doppler sonography in an experimental group (EG) of 50 scleroderma patients, not affected by cerebrovascular, ocular, hepatic diseases or nephropathy, before and after 3 days of Prostavasin infusion and before and after 3 days in a control group (CG) of 10 patients not receiving any treatment.

RESULTS

EG patients showed significant increasement in the brachial artery flow-mediated dilatation, in the portal vein velocity and in the splenic arterial PI (pre-Prostavasin vs post-Prostavasin treatment, p < 0.001) whereas CG patients had no significant changes. Values of the middle cerebral artery, the central retinal artery, the interlobar renal artery, the superior mesenteric artery and the hepatic artery RI were reduced after treatment in the majority of EG patients although the difference did not achieve a satisfactory statistical significance.

CONCLUSIONS

our results indicate that Prostavasin has a powerful effect in improving the peripheral circulation of scleroderma patients. Prostavasin significantly increases the portal vein flow but also the splenic arterial PI not supporting the hypothesis of its direct and specific action on relaxation of the hepatic micro circle.

Elastosonography in the diagnosis of the nodular breast lesions: preliminary report

PURPOSE

To assess the diagnostic accuracy of elastography in characterising nodular breast lesions.

MATERIALS AND METHODS

A total of 82 patients who received mammographic, ultrasonographic and elastographic evaluation in a single session at two Italian centres (Dept of Radiology, Az. Ospedali Riuniti, Ancona, and Ospedale Valduce, Como, Italy) between January and August 2004 according to identical protocols exhibited 91 nodules that were subjected to cytological/histological examination. Lesions were classified and scored and the sensitivity and specificity of elastography calculated.

RESULTS

Overall sensitivity and specificity were 79% and 89%, respectively. However, sensitivity was 86% and 65% and specificity 100% and 62% for lesions < 2 cm and > 2 cm in diameter, respectively. Despite the small sample and the fact that it does not include the full range of cell types, tumour cell composition seemed to affect accuracy.

CONCLUSIONS

Elastography is easy and rapid to perform. Larger studies are needed to establish semiological patterns; despite the small patient sample, these data provide an interesting contribution.

Ultrasonographic contrast-enhanced study of sicca syndrome

OBJECTIVE

To assess the ability of US contrast-enhanced time-intensity curves to depict the changes connected with sicca syndrome, a fairly common condition that is often associated with autoimmune disorders such as Sjogren's syndrome or other diseases. Diagnostic criteria are complex and controversial and although no single test can be considered the gold standard, salivary gland scintigraphy and biopsy are reliable diagnostic methods.

MATERIALS AND METHODS

Sixty consecutive patients with sicca syndrome, 40 of whom had primary (n = 23) or secondary (n = 17) Sjogren's syndrome and 20 had non-Sjogren's sicca syndrome, selected according to European Community Study Group diagnostic criteria for Sjogren's syndrome and subjected to contrast-enhanced US imaging of the parotids using a second-generation contrast agent with analysis of time-intensity curves at rest and during salivary stimulation, Tc99m salivary gland scintigraphy and labial gland biopsy.

RESULTS

In the 40 Sjogren's patients, US enhancement values were significantly lower (P < 0.0001 and P < 0.00003, respectively) than in the 20 non-Sjogren's patients both at rest and during stimulation. In the 23 subjects with the primary syndrome, values during stimulation were significantly lower than in the 17 subjects with the secondary syndrome (P < 0.0006), whereas at rest differences were not significant. Contrast-enhanced US imaging allowed to discriminate Sjogren's from non-Sjogren's sicca patients with 87.5% sensitivity, 85% specificity and 86.7% accuracy and the primary from the secondary syndrome with 78.2% sensitivity, 70.5% specificity and 75% accuracy. Interestingly, in eight patients with the primary syndrome, i.e. those with the more severe gland involvement, enhancement values were lower during stimulation than at rest.

CONCLUSION

Preliminary results indicate that contrast-enhanced US imaging can provide useful information on sicca characterisation and severity.

Liver cirrhosis: evaluation of haemodynamic changes using an ultrasound contrast agent

Liver cirrhosis is associated with haemodynamic changes. Using Levovist, we measured and compared Doppler signal arrival and peak enhancement times in the hepatic vein of patients with cirrhosis (n= 12) or chronic liver disease (n= 16) and in 12 healthy subjects. There were six patients with Child stage A, one patient with B, and five patients with C. The signal was recorded starting 20 s before contrast infusion until 2 h 20 min after its end. A software of the ultrasound (US) machine automatically sampled time-intensity values. Arrival times were significantly shorter (P < 0.001) in cirrhotic than non-cirrhotic (chronic liver disease + controls) and in patients with Child stage C compared with A. Differences in peak enhancement were weakly significant between cirrhotic and chronic patients (P < 0.04) and highly significant between the former and controls (P < 0.001), whereas differences between Child stages C and A were not significant (P > 0.05). Finally, cirrhotic patients had arrival times consistently shorter than 17 s. Automatic time-intensity curve analysis made measurements objective and conceptual error systematic, thus identifiable. Analysis of the passage of Levovist at the hepatic vein can thus become a non-invasive, well-tolerated and cost-effective diagnostic and monitoring tool in a larger number of patients with liver disease.

Contrast-enhanced power Doppler sonography of knee synovitis in rheumatoid arthritis: assessment of therapeutic response

The aim of this study was to evaluate the ability of power Doppler sonography (PDS) with ultrasound contrast agent to assess the synovial perfusion changes induced by intra-articular steroid injection therapy in the knee joints of patients with rheumatoid arthritis (RA). Eighteen RA patients (16 women, 2 men) with a history and signs of active knee synovitis were studied. Tenderness was evaluated using Thompson's modified index of synovitis activity. All patients underwent joint aspiration followed by intra-articular injection of 40 mg of triamcinolone hexacetonide. Gray-scale ultrasonography and PDS with an intravenous ultrasound contrast agent (Levovist) examinations were carried out before and 3 weeks after the intra-articular steroid injection. The calculation of the time--intensity curves provided a quantitative estimation of the synovial perfusion. The median values of the index of synovitis activity decreased significantly from 7.0 (95% confidence interval (CI) 6.0-8.0) to 3.0 (95% CI 2.0-4.0) ( p<0.01) 3 weeks after the intra-articular steroid injection. All patients showed a reduction of PDS signal after intra-articular steroid therapy and the baseline and follow up median values of the area underlying time-intensity curves were 7.48 (95% CI 5.79-8.73) and 2.45 (95% CI 1.92-3.61), respectively. The comparison between baseline and follow-up median values of the area under the curves showed a statistically significant reduction of PDS findings ( p<0.01). At follow-up examinations the changes in the index score of the synovitis activity were significantly correlated to the changes in the values of the area underlying time-intensity curves ( r=0.785; p<0.01). A significant correlation was also observed between baseline values of the area underlying time-intensity curves and C-reactive protein (CRP) ( r=0.548; p=0.023). In conclusion, PDS with an intravenous ultrasound contrast agent has been shown to be able to detect changes in synovial perfusion after intra-articular steroid injection and may be an additional useful method in the evaluation of synovial inflammation and in the assessment of the therapeutic response.

[Contrast-enhanced sonography in the diagnosis of renal artery stenosis: comparison with MR-angiography]

PURPOSE

To investigate the diagnostic accuracy of non-enhanced Colour-Doppler US and enhanced power-Doppler US in the diagnosis of renal artery stenosis compared with breath-hold Gd-DOTA-enhanced MR-angiography. Digital subtraction angiography (DSA) provided the gold standard.

MATERIALS AND METHODS

A total of 51 patients (19 women and 32 men, age ranging from 29 to 76 years) with clinical suspicion of renovascular hypertension underwent Colour-Doppler US of the renal artery; 11 subjects (21.6%) were excluded from the study as a complete and bilateral depiction of renal artery was not obtained. The remaining 40 subjects (14 women and 26 men) were investigated with power-Doppler US with time-intensity renal enhancement curve and with MR-Angiography. All of these subjects were also studied by DSA which provided the gold standard.

RESULTS

As stated, in 11 of 51 patients the diagnostic work-up was not completed because the initial US examination failed to depict the renal arteries. DSA showed renal artery stenosis in 16 of the remaining 40 patients. The sensitivity and specificity in diagnosing stenoses were 75% and 79.1% for conventional colour-Doppler US, 100% and 87.5% for enhanced power-Doppler US and 100% and 91.6% for MR-angiography.

CONCLUSIONS

MR-angiography is the most reliable technique in the diagnosis of renal artery stenosis. The sensitivity and specificity of enhanced power-Doppler US are superior to those of colour-Doppler US. Although MR-Angiography enables a better evaluation of renal artery stenosis, the good diagnostic accuracy of enhanced power-Doppler US, its greater acceptance by the patients and its wider diffusion support the use of this technique in the screening of patients with clinical suspicion of renovascular hypertension.

Ultrasonographic contrast agent: evaluation of time-intensity curves in the characterisation of solitary thyroid nodules

PURPOSE

To evaluate whether the time-intensity curve can improve characterisation of solitary thyroid nodules.

MATERIAL AND METHODS

From June to December 2000 we studied 61 patients (16 men and 45 women, mean age 46 years) with solitary thyroid nodules that were not associated with any important hormonal alteration and that showed poor tracer uptake at scintigraphy. We evaluated the Power Doppler vascular pattern before and after a 60" intravenous injection of 2.5 g of Levovist (diluted in 7 ml). The study lasted 5 minutes from the beginning of the infusion. Finally, the time-intensity curves were processed. All the nodules underwent fine needle aspiration biopsy (FNAB) and excision biopsy.

RESULTS

Histology revealed 43 benign lesions and 18 malignant lesions. At contrast-enhanced Power Doppler 83.4% (15/18) of the malignant nodules were found to be hypervascularized, while 16.6% (3/18) were hypovascularized. Of the benign lesions, 90.7% (39/43) were hypervascularized, 9.3% (4/43) were hypovascularized. All the nodules, both hyper- and hypovascularized, displayed rapid and intense wash-in curves. By contrast, the wash-out curves were regular and monophasic in 40/43 (93%) benign lesions (36 hypervascularized and 4 hypovascularized lesions) and irregular and polyphasic in 16/18 (89%) malignant lesions (13 hypervascularized and 3 hypovascularized lesions); 3/43 (7%) benign nodules showed polyphasic wash-out and 2/18 malignant lesions (11%) showed monophasic wash-out.

DISCUSSION AND CONCLUSIONS

Time-intensity curves, and particularly wash-out curves, provide useful information for the characterisation of solitary thyroid nodules. 93% of benign nodules (with regular vascularization) showed a monophasic pattern of the wash-out curve, while 89% of malignant nodules ("anarchical" vascularization) had polyphasic wash-out curves. This behaviour was observed in both hypervascularized and hypovascularized lesions. Our method proved to have a sensitivity of 88% and a specificity of 93%. The study of time-intensity curves could therefore enable us to differentiate between benign and malignant lesions and characterise hypovascularized malignant nodules which would not be observed without contrast agent.

Color Doppler sonography

The authors report the results obtained with color Doppler sonography in the study of breast conditions. Color Doppler allows to detect the following main features in breast conditions: the presence of blood flow, vessel arrangement, vascularization extent, the number of vascular poles. To investigate slow flows, it is better to use low PRF values (not above 1 KHz) and low filters, while amplification should be set immediately above the system's noise threshold; the size of color Doppler box should be adjusted as small as possible to maximize sensitivity and minimize flash artifacts. In May 1992 to September 1997, 252 patients with solid breast masses were examined with mammography, B-mode, color Doppler and power Doppler sonography (only 57 cases). We identified histologically (176 cases) or cytologically (77 cases) 141 carcinomas and 112 benign solid lesions. The diameter of the 141 carcinomas ranged 0.4-4 cm (mean 1.7), while the diameter of benign lesions ranged 0.7-3 cm (mean 1.5). The malignancy pattern was characterized by hypervascularity (92.9%), irregular and abundant (54.2%) vascularization and more than one vascular pole. Benign lesions were avascular (43.4%) with poor and peripheral vascularity (90%) and mostly showed only one vascular pole. The avascular cancers (10 cases) were three mucoid, five in situ and two small (0.7 and 0.9 cm) invasive ductal carcinomas. The six benign lesions with irregular and abundant vascularization and more than one vascular pole were proved to be two proliferating and three juvenile fibroadenomas and one phylloid tumor. These results are encouraging and suggest that this technique can be a useful adjunct to mammography and sonography in the differential, diagnosis of breast nodules.

[Doppler color ultrasonography in the diagnosis of diffuse hyperthyroidism]

Graves disease is an organ-specific autoimmune disorder characterized by variable clinical and laboratory patterns and by alternating remissions and relapses. We investigated if a correlation exists between the hypervascular pattern of Graves disease, studied with color Doppler US (CDUS), and the degree of thyroid hyperfunction, estimated according to biohumoral parameters. We also investigated if CDUS can differentiate, with the help of pathologic correlations, the glandular histologic patterns recently reported in the literature in thyroidectomized patients. Forty-five patients with Graves disease were selected and submitted, in the same day, to CDUS and to a clinical biohumoral test, including hormone and antibody assays. Eight of these patients had undergone total thyroidectomy. The following variables were studied in each patient: US structure and glandular thickness, color spot distribution, VP, R1, T3, T4, TRab, Tmab, Tgab and patient's age. Thirty-three normal volunteers were also examined. CDUS demonstrated two patterns: pattern A consisted in many homogeneous and bilobed color spots all over the glandular structure; pattern B consisted in color spots areas and/or vascular bands surrounding avascular areas. Pattern A was seen in 13/45 patients (28.9%) and pattern B in 32/45 (71.1%). The subdivision into two groups showed significant differences from a statistical point of view (0.05 > p > 0.001) in relation to the following indices: Vp, T3 and gland size. Of the 8 patients submitted to total thyroidectomy, 3 had pattern A and 5 had pattern B at CDUS. Histology showed major differences between the two groups: thus, thyroidectomized patients with pattern B had thickened interlobular septa and more nodules. with reduced vascular component. Our study confirms that CDUS can diagnose hyperthyroidism; moreover, this technique seems to be capable of differentiating, with the help of color and flow velocity analyses, two different abnormal patterns, which we called A and B. The early results of this preliminary study seem to indicate that CDUS can show two distinct patterns of Graves disease, which differ from a histologic viewpoint and probably also in clinical aggressiveness.

[Nonpalpable lesions of the breast. Diagnostic potentials of the stereotaxic-guided radiogram]

PURPOSE

To investigate the diagnostic capabilities of the stereotaxic technique in characterizing suspicious mammographic findings for which stereotaxic FNAB is indicated.

METHOD

January, 1990, through December, 1992, 871 patients underwent stereotaxic mammograms preliminary to FNAB; in 12 of them (1.4%) mammography could rule out the malignant nature of the lesions, thus making FNAB useless.

MATERIAL

Stereotaxic images were acquired with a conventional mammographic unit (Senographe 500 or 600T CGR-GE). An average 34 months' mammographic follow-up confirmed the absence of malignancy in the above patients. The most common glandular structure in these patients was investigated, together with the type of nonpalpable lesions found on conventional mammograms (opacity, local distortion or scar, microcalcification without a mass) and the reasons why FNAB was unfeasible, or useless. In our patients FNAB was unfeasible mostly in fatty breasts (9/12), while lesion type was not relevant for screening. The lesions were 5/12 distortion, 5/12 small opacities and 2/12 clusters of small microcalcifications. In 9/12 patients FNAB was not performed because the image observed on conventional exams had disappeared, in 2/12 patients with microcalcifications because they were scattered on a large glandular area and in 1/12 patients because vascular sinuosity was diagnosed.

[Echo Doppler in the characterization of thyroid nodular disease]

This study was aimed at investigating role and efficacy of color-Doppler US in the characterization of thyroid nodules. Eight-three consecutive patients with only one solid thyroid nodule, not smaller than 0.8 cm, were examined. They were submitted to scintigraphy and laboratory tests first and then to color-Doppler US, to fine-needle biopsy and/or to histologic examinations. Color-Doppler US examinations were performed with a 7.5 MHZ linear probe, 5-MHz Doppler frequency, PRF = 0.8 KHz, 40-50 degrees insonation angle, wall filters at the lowest level, 2-5 mm sample volume, color and Doppler gains set at 30-50% and asynchronous data collection. The final diagnosis, made at cytology and/or histology, showed 43 follicular hyperplasias, 19 follicular adenomas and 21 carcinomas. The following US variables were considered: nodule size, site, margins and the possible presence of the "halo sign" pattern, with a special attention paid to micro-/macrocalcifications, signs of invasion of surrounding anatomic structures and possible adenopathies. With color-Doppler US, we studied presence and distribution of nodular vascularization, peak (Vp) and middle (Vm) velocity, resistive index (RI) and Doppler spectrum morphology. In agreement with the current literature, 3 patterns of nodular vascularization were considered: not apparent, or type I (3/83), which was found only in follicular hyperplasia; peripheral, or type II (46/83) and finally, peri- and intranodular, or type III (31/83). Hyperplasias exhibited a type I pattern rarely and exclusively and, if vascularized, they always exhibited Vp < 50 cm/s, Vm < or = 40 cm/s and mostly (39/40 RI < or = 0.75; adenomas were always vascularized, with Vp > 50 cm/s and mostly (18/19) RI < or = 0.75; primary or secondary tumors were always vascularized, with an extremely variable distribution, and if Vp < 50 cm/s, their RI > 0.75, while if Vp < 50 cm/s, their RI was independent of the threshold value of 0.75. These preliminary conclusions seem to confirm that vascular patterns alone are not particularly helpful, compared with B-mode US results, in distinguishing among thyroid nodules. Nevertheless, Vp and RI may be of great usefulness in the characterization of solid nodules and in the selection of the patients to submit to fine-needle biopsy.

[Doppler echography and color Doppler echography in the assessment of the vascular functional aspects of medical nephropathies]

This study was aimed at finding a Doppler parameter to distinguish, among medical nephropathies, the ones with glomerular from those with vascular or tubulointerstitial involvement. Therefore, 32 patients (20 men and 10 women, average age: 43 years, range: 10-77 years) with clinical and laboratory signs of medical renal disease were examined with color-Doppler US. The resistive index (RI, n.v. < 0.70), as calculated from the Doppler waveform signal was especially considered to assess eventual significant changes differentiating renal diseases according to the different kinds of involvement. RI values were compared with renal biopsy findings, creatininemia levels and clinical and laboratory variables as hematuria and proteinuria. Histology diagnosed 18 glomerulonephritis, 4 glomerulonephritis with interstitial involvement and 10 vascular and tubulointerstitial nephroses, with 1 tubular necrosis. Doppler US demonstrated a normal RI value in 17/18 patients with glomerulonephrosis (mean value: 0.59 +/- 0.05). In one case only, even though biopsy indicated the involvement of one glomerulus only (membranous GN II stage), RI was high--i.e., 0.79. In 4 patients with simultaneous glomerular and interstitial involvement, the mean RI value was 0.17 +/- 0.01. In the 10 cases of tubulointerstitial or vascular nephrosis, the RI was 0.83 +/- 0.07. As far as the correlation between creatininemia levels and RI is concerned, in 8 patients with high values (1.5-8 mg/dl), the mean RI was 0.72 +/- 0.08 and only a weak correlation was found between the RI and the renal failure degree as expressed by creatininemia levels. Therefore, the RI seems to be related more to the site of the disease in the renal field than to renal failure degree. Doppler US seems to be capable of characterizing medical nephrosis, distinguishing glomerular from vascular or tubulointerstitial involvement. In this application area, the combined use of Doppler and color-Doppler US allowed each examination to be performed in a relatively short time--i.e., 30 minutes on the average.

Appropriateness of the use of clinical and radiologic examinations and laboratory tests in the follow-up of surgically-treated breast cancer patients. Results of the Working Group on the Clinical Aspects of Follow-up

BACKGROUND

The aim of this working group was to assess the appropriateness of use of radiologic examinations, laboratory tests and periodic check-ups for surgically-treated, disease-free breast cancer patients.

MATERIALS AND METHODS

A total of 252 clinical scenarios (36 for each of the 8 exams considered: clinical examination, mammography, chest roentgenography, hematochemical tests, markers, bone scan, liver echography/abdominal CT scan), each representing a specific surgically treated and disease-free breast cancer patient, were rated by the members of the panel. A 3 point scale was utilized as to whether the test in question was judged inappropriate (1), questionable (2), or appropriate (3) (in the latter case the panel member was also asked for the advised frequency of the exam expressed in months).

RESULTS

After two assessment sessions, consensus among members of the panel was reached on 216 of the 252 scenarios; disagreement remained on only 36 clinical scenarios.

CONCLUSIONS

The panel agreed that only clinical examinations and mammographies should be recommended for routine clinical follow-up of surgically-treated breast cancer patients. Given the current available therapeutic options, these would assure adequate medical care and psychological aid.

[Magnetic resonance versus traditional breast imaging in solid nodular diseases of the breast]

We report and compare the results obtained with conventional imaging (mammography and US) and MRI in the study of 46 solid nodular breast lesions verified with histologic, cytologic and/or instrumental follow-up examinations for 12-34 months. The variables we compared were relative to the identification, nature and size of the lesions. MRI, which was performed on the basis of previous mammographic and US findings, detected all the lesions but never modified the diagnosis of conventional imaging methods. Questionable MR diagnoses were fewer than mammographic and US ones (2 versus 11), but its role in correcting the questionable diagnoses of conventional imaging methods was controversial. Particularly, of 11 such cases on mammographic and US images, MRI made 8 correct diagnoses but exhibited 2 false positives and 1 false negative for carcinoma. Such MR mistakes are likely to be related to the non-use of contrast medium. As for size, US was more accurate than mammography and MRI; yet, very few misdiagnoses were make on the whole.

Inadequacy of ultrasonography for monitoring response to treatment of liver metastases

PURPOSE

We prospectively evaluated the clinical efficacy of ultrasonography (US) in monitoring the effect of medical treatment in patients with liver metastases, by comparing serial US assessment with serial magnetic resonance imaging (MRI) evaluation and clinical outcome in a group of 41 patients with solid tumors.

PATIENTS AND METHODS

Both examinations were performed in patients with metastatic liver disease at the start of a new treatment modality and monthly thereafter for 3 months; close monitoring was prolonged beyond the third month in cases in which there was disagreement between the two techniques and the clinical course was not conclusive.

RESULTS

Planned follow-up was completed in 37 cases. There was limited concordance between the two examinations: in 21 cases only (56.8%), US and MRI gave concordant information on the evolution of hepatic metastases; in eight cases, both agreed on progression of disease (PD), in 11 cases on stable disease (SD), and in one case each on partial response (PR) and complete response (CR). In the remaining 16 cases (43.2%), there was disagreement between the two examinations. On the basis of subsequent clinical course, this discrepancy was shown to be due to US inadequacy in 13 cases and to MRI inadequacy in one case; in two cases, the clinical course was not conclusive. The most striking limits of US appeared to be twofold: (1) a progressive appearance, with chemotherapy, of a diffusely inhomogeneous structure of the liver, resulting in obscuration of focal lesions (and a subsequent judgement of CR) in cases in which lesions were, on the contrary, detected at MRI and usually confirmed by subsequent clinical course; and (2) false US-determined PD in cases in which lesions proven at baseline MRI were noted at US only after one to two courses of therapy.

CONCLUSION

We conclude that US, which is known to be inaccurate for screening of liver metastases, is unreliable for the follow-up of metastatic liver disease; despite its wide availability, low cost, and noninvasiveness, critical therapeutic decisions should not be made based on the outcome of this test.

[Treatment of Plummer's adenoma: correlation between ultrasonography-guided percutaneous injection of ethanol and autoimmunity]

The authors investigated the value of percutaneous ethanol injection in the treatment of Plummer's adenoma. Ten patients were studied: they exhibited a single, hot and toxic nodule in the thyroid. Thyroid autoimmunization (TSAb; TMAb; TGAb) and function (T3; T4; TSH; FT3; FT4) were studied in all patients, before treatment and at 1 month and 3 months. Scintigraphy with 99Tc was performed at the same time intervals. In the euthyroid stage, alcoholization was preceded by US and cytology. Three-four ml of ethanol 95 degrees were injected once or twice a week, from a minimum of 3 to a maximum of 8 injections. Treatment was successful in 2 cases; partial success was obtained in 4 cases, and in 4 cases treatment failed. In all successful cases antibodies were negative and the nodules had hypoechoic echostructure, with a peripheral hypoechoic halo and no areas of internal colliquation. Thus, US-guided percutaneous alcoholization seems to be capable of correct indications in hypoechoic nodules not exhibiting areas of colliquative necrosis and with negative antibodies. However, the problem of the dose of alcohol to inject to treat the nodule thoroughly is still to be debated.