Preoperative Role of Superb Microvascular Imaging and Shear-Wave Elastography for Prediction of Axillary Lymph Node Metastasis in Patients With Breast Cancer

ABSTRACT

This study aims to evaluate the role of shearwave elastography (SWE) and superb microvascular imaging (SMI) for preoperative prediction of axillary lymph node metastasis (ALNM) in patients with breast cancer. In a cohort of 214 women with breast cancer, B-Mode ultrasonography (US), SMIvascular-index (SMIvi), and SWE (E-mean, E-ratio) values were recorded before tru-cut biopsy. Axillary fine-needle aspiration biopsy (FNAB) and sentinel lymph node sampling results were collected. Imaging findings and histopathological data were statistically compared. Receiver operating characteristic curve analysis was used to evaluate diagnostic performance. Reverse stepwise logistical regression analysis was conducted. Although ALNM was negative in 111 cases, it was positive in 103 patients. Axillary lymph node metastasis (+) group had larger size (P < 0.001), higher vascularization (SMIvi: 8.0 ± 6.0 versus 5.0 ± 4.3, P < 0.001), and higher elasticity value (E-mean: 129 ± 31 kPa versus 117.3 ± 40 kPa, P = 0.014). Axillary lymph node metastasis was observed statistically more frequently in Her-2 positive cases (P = 0.005). There was no significant difference between other B-mode US findings (P > 0.05), SMI Adler (P = 0.878), and E-ratio (P = 0.212). The most appropriate cutoff value for the prediction of ALNM was 23.5 mm for size, 3.8 for SMIvi, and 138.5 kPa for E-mean. The most sensitive (77%) method was the SMIvi measurement, while the most specific (86%) finding was Her-2 positivity. The combined model (being Her-2 positive, >23.5 cm, and >3.8 SMIvi) increased the specificity (78%), PPV (71%), and accuracy (68%). Although the increased size is a previously studied parameter in predicting the risk of ALNM, Her-2 and data obtained by SWE, and SMI can be used to assist conventional US.

The Diagnostic Role of Shear Wave Elastography and Superb Microvascular Imaging in the Evaluation of Suspicious Microcalcifications

OBJECTIVES

The aim of this study was to investigate the role of superb microvascular imaging (SMI) and shear wave elastography (SWE) in the prediction of malignancy and invasiveness of isolated microcalcifications (MC) that can be visualized by ultrasonography (US).

MATERIAL AND METHODS

Sixty-seven women with MC, who were considered suspicious on mammography were evaluated. Only those lesions that could be visualized by US and presented as non-mass lesion were included. They were evaluated by B-mode US, SMI, and SWE before US-guided core-needle biopsy. B-mode US, SMI (vascular index (SMIvi)), and SWE (E-mean, E-ratio) findings were compared with histopathologic features.

RESULTS

Pathology confirmed 45 malignant (21 invasive and 24 in situ carcinomas) and 22 benign lesions. There was a statistically significant difference between malignant and benign groups in terms of size (P = .015), distortion (P = .028), cystic component (P < .001), E-mean (P < .001), E-ratio (P < .001), and SMIvi (P = .006). For differentiation of invasiveness E-mean (P = .002), E-ratio (P = .002), and SMIvi (P = .030) were statistically significant. According to ROC analysis E-mean (cut-off point at 38 kPa) was the most sensitive (78%) and the most specific (95%) value among four numeric parameters (size, SMI, E-mean, and E-ratio) with AUC = 0.895, PPV = 97%, and NPV = 68% in detecting malignancy. In the evaluation of invasiveness, the most sensitive (71.4%) method was SMI (cut-off point at 3.4) and the most specific (72%) method was E-mean (cut-off point at 91.5 kPa).

CONCLUSION

Our study shows that adding SWE and SMI to the sonographic evaluation of MC would be an advantage for US-guided biopsy. Including suspicious areas according to SMI and SWE in the sampling area can help target the invasive part of the lesion and avoid underestimation of core biopsy.

INCREASED ARTERIAL STIFFNESS AND ACCELERATED ATHEROSCLEROSIS IN TAKAYASU ARTERITIS

INTRODUCTION

Cardiovascular diseases are the leading causes of morbidity and mortality in patients with Takayasu arteritis (TAK). Arterial stiffness and accelerated atherosclerosis have been reported in TAK, however, morphological changes in the arterial wall have not been adequately addressed. Shear wave elastography (SWE) is a new, non-invasive, direct and quantitative method of ultrasonography (US) that evaluates elasticity of biological tissues.

METHODS

A total of 50 patients with TAK (44F/6 M; mean age: 39.8 ± 8.2 years), 43 with systemic lupus erythematosus (SLE) (38F/5 M; 38.0 ± 7.9 years) and 57 healthy controls (HCs) (50F/7M: 39.5 ± 7.1 years) were studied using carotid B mode US and SWE. Carotid artery intima-media thickness (CCA IMT) and SWE were measured and the atherosclerotic plaques were recorded. Clinical characteristics and cardiovascular risk factors were determined. Intra and inter observer reproducibility was assessed and found good agreement.

RESULTS

The mean IMT in the right and left carotid arteries was significantly higher only among patients with TAK when compared to SLE and HCs. Carotid artery plaques were significantly increased only in patients with TAK. On the other hand, the mean SWE value was significantly increased among both TAK and SLE patients when compared to HCs, whereas patients with TAK had the highest value. These were also true after adjustments were made for atherosclerotic risk factors and after all those with atherosclerotic plaques were excluded from the analysis. TAK itself, diastolic blood pressure levels and IMT were independently associated with SWE.

CONCLUSIONS

Markedly increased CCA IMT and SWE values appear to be uniquely associated with TAK, suggesting that they could be used as diagnostic tools. Arterial stiffness occurs independently from atherosclerosis and is associated with arterial thickening. Further studies should investigate whether CCA SWE values could predict cardiovascular morbidity and mortality. Strong association with premature atherosclerosis could be also considered as a unique feature of TAK.

Shear wave elastography evaluation of liver, pancreas, spleen and kidneys in patients with familial mediterranean fever and amyloidosis

OBJECTIVES

Amyloid deposits in a visceral organ can contribute to tissue stiffness that could be measured with shear wave elastography (SWE). We aimed to investigate changes in organ stiffness in conjunction with laboratory parameters in patients with Familial Mediterranean Fever (FMF) and amyloidosis.

METHODS

This prospective study included 27 FMF patients, 11 patients with amyloidosis, and 38 healthy controls. Median shear wave elasticity values of the liver, spleen, both kidneys, and pancreas on SWE were compared among study and control groups. The mean values of CRP (C-reactive protein) and ESR (erythrocyte sedimentation rate) were compared by the t-test and the median of SAA (serum amyloid A protein) was compared with the Mann-Whitney U test between FMF groups with and without amyloidosis. Spearman's correlation analysis was performed to reveal the association between stiffness values and laboratory parameters.

RESULTS

The median liver, spleen, kidney, and pancreas elasticity values were significantly higher in the FMF group with amyloidosis compared to control subjects. The median kidney stiffness values in the FMF group with or without amyloidosis were significantly higher compared to control subjects. Median liver stiffness values in FMF patients with amyloidosis were significantly higher than FMF patients without amyloidosis. There were statistically significant positive correlations between the CRP (p = 0.001, r = 0.56), ESR (p = 0.001, r = 0.61), and SAA (p = 0.002, r = 0.53) levels with spleen stiffness, and CRP (p = 0.006, r = 0.48) and ESR (p = 0.001,r = 0.61) levels with pancreas stiffness, and ESR (p = 0.004, r = 0.51) levels with the left kidney stiffness.

CONCLUSION

SWE could be a potential tool for noninvasive follow-up of FMF patients and also amyloid deposition.

ADVANCES IN KNOWLEDGE

Both acute inflammation and amyloidosis in the FMF patients could increase organ stiffness.

The Role of Superb Microvascular Imaging and Shear Wave Elastography in Differentiation of Thyroid Nodules from Intrathyroidal Ectopic Thymus in Children

BACKGROUND

Ectopic thymus could be located intrathyroidal, therefore fine ultrasound details are useful for this differentiation.

AIM

To investigate differences in stiffness and vascularity properties among thyroid nodules and intrathyroidal ectopic thymus (IET) by obtaining quantitative data in children.

PATIENTS AND METHODS

Twenty-seven thyroid nodules and 20 IET in children were evaluated in terms of vascularity index (VI) via superb microvascular imaging (SMI) and stiffness by shear wave elastography (SWE). Differences in the volume, VI, and SWE parameters of the lesions were assessed by using the Mann-Whitney U test. Association of the age, lesion volume, SWE, and VI parameters was investigated by using Spearman's correlation analysis. The optimal cut-off values for stiffness and vascularity in the differentiation of nodules from IET were calculated with ROC analysis.

RESULTS

The median (range) age of the participants with thyroid nodules and IET were 15.6 (10-18) years and 8.8 (3-14) years, respectively. The medians (range) VI of the IET and thyroid nodules were 4.7 (0.2-16) % and 23.8 (7.5-40)%, respectively. The median SWE values were 7.6 (4.4-9.5) kPa and 15.58 (8.5-23.4) kPa for IET and nodules, respectively. There have been highly significant differences among medians of volume, SWE, and VI values of the lesions. Significant positive correlations were found between VI and SWE parameters (p=0.001, r=0.64), and volume with VI (p=0.018, r=0.34) and SWE (p:0.001, r= 0.5). The diagnostic accuracies were 93%, 91% with the cut-off values as 9.2 kPa, 13% for the SWE and SMI, respectively. IETs were found to be less vascular and less stiff than thyroid nodules.

CONCLUSIONS

IETs could be easily and confidently differentiated from nodules using SWE and SMI quantifications. This discrimination prompts the reduction of unnecessary interventional procedures.

Evaluation of the thyroid disorders in children with familial Mediterranean fever

Although it is well-known that autoimmune thyroid diseases are more common in most of the autoimmune connective tissue diseases, the relationship between autoinflammatory diseases and autoimmune thyroid diseases has not well-evaluated yet and still remains unclear. The aim of this study was to investigate the frequency of autoimmune diseases of the thyroid gland and to evaluate thyroid function tests in children with familial Mediterranean fever. Thyroxine, thyroid-stimulating hormone, and thyroid autoimmune markers such as thyroid peroxidase and thyroglobulin antibodies, and thyroid ultrasound findings of 133 patients with familial Mediterranean fever and 70 healthy controls were evaluated. Serum levels of thyroid-stimulating hormone, free thyroxine, and thyroid autoimmunity markers were similar in patients with familial Mediterranean fever compared with healthy controls. There was no relationship between the duration of the disease and thyroid-stimulating hormone, free thyroxine, anti-thyroid peroxidase, and anti-thyroglobulin levels. This study revealed that incidence of thyroid dysfunction and autoimmunity is not increased in patients with familial Mediterranean fever. In conclusion, routine screening of serum thyroid function tests and thyroid antibody levels is not required in patients with familial Mediterranean fever in the absence of clinical symptoms or family history. Key Points • It is well-known that autoimmune thyroid diseases are common in autoimmune diseases. • The relationship between autoimmune thyroid diseases and autoinflammatory diseases like familial Mediterranean fever is still unclear. • In this study, we report the similar frequency of the autoinflammatory thyroid diseases in patients with familial Mediterranean fever and healthy controls. • A routine screening of serum thyroid function tests and thyroid antibody levels may not be required in patients with familial Mediterranean fever in the absence of clinical symptoms or family history.

Superb Microvascular Imaging in the Evaluation of Pediatric Graves Disease and Hashimoto Thyroiditis

OBJECTIVES

We aimed to investigate the differences between spectral Doppler and Superb Microvascular Imaging (SMI; Canon Medical Systems, Tokyo, Japan) findings in children with Hashimoto thyroiditis (HT) and Graves disease (GD) compared to healthy control participants.

METHODS

The study included 34 patients with GD, 37 patients with HT, and 22 healthy volunteers. All patients with HT and 11 patients with GD were euthyroid; 23 patients with GD had symptoms of hyperthyroidism and had thyrotropin values of less than 0.5 mIU/L. Thyroid volumes, mean resistive indices, and peak systolic velocities along with vascularity indices (VIs) on Superb Microvascular Imaging were measured.

RESULTS

Patients with GD had a significantly higher mean thyroid volume (P < .001; right lobe, 11.80 mL; left lobe, 9.10 mL) and peak systolic velocity (right, 32.5 cm/s; left, 30 cm/s) with a lower resistive index (right, 0.48%; left, 0.48%) compared to patients with HT (right, 8.78 mL, 20 cm/s, 0.55%; left, 7.41 mL, 20 cm/s, 0.55%, respectively) and also control participants (right, 4.59 mL, 15 cm/s, 0.56%; left, 3.52 mL, 15 cm/s, 0.54%). Patients with GD had a significantly higher median VI (right, 25%; left, 26%) compared to patients with HT (right, 11%; left, 13%) and control participants (right, 8%; left, 8%). When patients with GD were categorized as euthyroid and hyperthyroid based on thyrotropin levels and clinical symptoms, both euthyroid and hyperthyroid patients with GD had significantly higher thyroid volumes compared to patients with HT (P < .001). Hyperthyroid patients with GD had higher thyroid volumes compared to euthyroid patients with GD; however, the difference failed to reach statistical significance. A significant strong positive correlation with the VI and thyrotropin receptor autoantibody levels (r = 0.696) was found. The highest area under the curve was obtained for the right lobe VI (0.885), followed by the left lobe VI (0.872), right lobe volume (0.828), and peak systolic velocity (0.810). The optimal cutoff VI value for distinguishing between HT and GD was 17.35% with sensitivity, specificity, and diagnostic accuracy of 85.3%, 78.4%, and 81.7%, respectively.

CONCLUSIONS

Superb Microvascular Imaging is a new method that can detect subtle vascularity changes with higher accuracy compared to spectral Doppler parameters in distinguishing between HT and GD.

Multi-parametric Ultrasound Evaluation of Pediatric Thyroid Dyshormonogenesis

The aim of this study was to assess the diagnostic contribution of gray-scale ultrasonography, color Doppler, superb microvascular imaging and shear wave elastography in thyroid dyshormonogenesis (TD). From October 2017 to February 2018, the prospective study included 31 patients (13.6 y; 11-14 y) diagnosed with TD based on thyroid scintigraphy and perchlorate discharge tests and 40 healthy pediatric volunteers (12.8 y; 10-16 y). Median resistive indices (RIs), peak systolic and end-diastolic velocities, vascularity indices (VIs) via superb microvascular imaging and shear wave elastography parameters were evaluated. Median VI values were significantly higher and median RI values were significantly lower in the study group than the control group. No significant difference was found between shear wave elastography parameters of the TD and control group. VI was significantly correlated with median total thyroid gland volumes (p = 0.002, r = 0.28), medication dosage (p = 0.03, r = 0.48) and 2-h radioactive iodine uptake values (p = 0.008, r = 0.57). VI is a clinically significant and novel parameter useful for diagnosing TD.

An unusual presentation of sixth nerve palsy: neurobrucellosis

Abducens nerve palsy is generally seen in older patients with diabetes and hypertension. It is relatively rare in young and otherwise healthy patients. An extensive differential diagnosis is considered in patients younger than 50 years of age who develop a sixth nerve palsy. We report here a 25-year-old patient from Turkey who was admitted with sixth nerve palsy as a component of neurobrucellosis. She was referred to our clinic because she had double vision and restricted right eye abduction. During the ophthalmic examination, both pupils were round and reactive to light and accommodation. Extraocular movements were intact with the exception that the right eye was unable to abduct. Magnetic resonance imaging revealed no pathology. She also had a diagnosis of brucellosis and her abducens nerve palsy was a form of clinical manifestation of neurobrucellosis. We conclude that neurobrucellosis should be considered in patients with sixth cranial nerve palsy especially in areas where brucellosis is endemic.

Effects of static stretching duration on muscle stiffness and blood flow in the rectus femoris in adolescents

AIMS

To compare the effects of 2 and 5 min of passive static stretching (SS) on stiffness and blood flow in the rectus femoris in adolescent athletes using shear wave elastography (SWE) and superb microvascular imaging (SMI).Material and methods: This prospective study included 20 male athletes with median age of 14.5 (12.5-16.5) years. The subjects were divided into two groups based on the SS duration as follows: 2 min (n=10) and 5 min (n=10). At rest and after 2 and 5 min of SS, stiffness and blood flow values were compared in the rectus femoris for each group. Inter-operator reliability was also analysed.

RESULTS

There was no significant difference between resting and 2 min of SS in terms of stiffness. The stiffness values decreased significantly from resting to 5 min of SS. The blood flow increased significantly from resting to 2 and 5 min of SS. Inter-operator reliability was moderate to perfect for SWE and SMI measurements (ICC: 0.52-0.83).

CONCLUSIONS

 SWE and SMI can be used to acquire reliable quantitative data about muscle stiffness and blood flow in adolescents. While stiffness parameters significantly decreased from resting after only 5 min, blood flow significantly increased both after 2 and 5 min. For physical rehabilitation protocols, 5 min of SS may be chosen to reduce stiffness. For competitions, 2 min of SS may be sufficient for warm-up exercise because it increases the blood flow optimally. Five min of SS may be preferred for the cool-down exercise to enhance recovery.

Severe Multisystem Involvement of Chronic Granulomatous Disease in a Pediatric Patient

Chronic granulomatous disease (CGD) is a rare primary immunodeficiency disorder identified by recurrent pyogenic and fungal infections infections secondary to defective nicotinamide adenine dinucleotide phosphate oxidase enzyme. In the present study, we demonstrated a case with a history of multiple segmental lung resections because of invasive bronchopulmonary aspergillosis, multifocal hepatic and splenic granulomas, bilateral adnexal calcific foci presumed to be related with old granulomatous infection and finally gastric outlet obstruction secondary to the involvement of the stomach wall thickening with granulomatous tissue. This is an extremely severe case of CGD with multiorgan involvement within a 10-year period after the diagnosis. Gastric antral involvement may mimic inflammatory bowel diseases in such cases, and intestinal involvement can reliably be demonstrated via ultrasonography. Spontaneous resolution of the antral involvement was observed in the follow-up.

Echogenic lymph nodes in the differential diagnosis of pediatric sarcoidosis

We present a delayed diagnosis of sarcoidosis in an 11-year-old girl by demonstrating ultrasonographic imaging findings of granulomatous cervical and abdominal lymph node involvement. Pulmonary interstitial fibrosis in addition to multi-compartmental enlarged echogenic lymph nodes could be considered sarcoidosis. Punctate echogenic foci in the cervical lymph nodes should be considered in the differential diagnosis of sarcoidosis.

Shear Wave Elastography in the Evaluation of the Kidneys in Pediatric Patients with Unilateral Vesicoureteral Reflux

OBJECTIVES

To evaluate the ability of shear wave elastography (SWE) to detect renal parenchymal scar formation in patients with vesicoureteral reflux.

METHODS

We prospectively evaluated 49 patients with unilateral grade 2 or higher-degree VUR. All patients underwent dimercaptosuccinic acid (DMSA) scintigraphy for evaluation of the renal parenchymal scar. After the DMSA scan, 2 radiologists, who were blinded to clinical data and each other's measurements, evaluated the kidneys of the patients using SWE. The kidneys were divided into 3 parts: upper pole, middle region, and lower pole, and 3 regions of interest were placed to each part. Shear wave velocity (SWV) values were calculated using meters per second as a unit and recorded for each region. Afterward, SWV values were compared to DMSA results.

RESULTS

There was no significant difference between the observers' mean SWV values of kidneys with VUR without scar formation (mean ± SD, 2.11 ± 0.06 and 2.09 ± 0.05 m/s) and the contralateral normal kidney SVW values (2.11 ± 0.06 and 2.10 ± 0.05 m/s; P = .936 and .724, respectively). We observed a significant difference between the mean SWV values of the kidneys with VUR accompanied by scar formation (2.28 ± 0.10 and 2.27 ± 0.11 m/s) and the mean SWV values of the contralateral normal kidneys (2.09 ± 0.05 and 2.10 ± 0.04 m/s; P < .001 for both observers).

CONCLUSIONS

Shear wave elastography could detect scar tissue in kidneys; however, the variability of the stiffness due to the kidney's complex structure, and variations in blood perfusion and the glomerular filtration rate of the kidney might limit the use of SWE in current clinical diagnostic algorithms for VUR.

Shear wave elastography of parotid glands in pediatric patients with HIV infection

OBJECTIVES

Parotid gland (PG) involvement is common among the patients with HIV infection. Shear wave elastography (SWE) is a noninvasive method used to measure the tissue stiffness of several organs including PG. The aim of this study was to evaluate the tissue stiffness values of PGs of HIV-infected children via SWE and compare the results with the counterparts of healthy subjects.

MATERIALS AND METHODS

This single-center, prospective study included the PG examinations of 23 pediatric HIV patients and 40 healthy children via grayscale ultrasound and SWE. Independent sample T test and Mann-Whitney U test were used in statistical analysis.

RESULTS

Stiffness of both PGs was significantly higher in patients' group when compared with control subjects. In addition, when the patients were separated into two groups according to the appearance of PG on grayscale ultrasound as homogeneous and heterogeneous, stiffness values were increased in the patients with homogeneous parenchymal appearance. No significant difference was achieved in terms of median CD4 and CD8 counts, HIV RNA levels or median duration of illnesses.

CONCLUSIONS

PG examination of HIV-infected children via SWE reveals increased tissue stiffness when compared with healthy subjects. SWE can be used as an ultrasound-assisted noninvasive technique in this manner.

Assessment of paediatric Hashimoto's thyroiditis using superb microvascular imaging

AIM

To evaluate the role of superb microvascular imaging along with greyscale and Doppler imaging for thyroid gland evaluation in Hashimoto's thyroiditis (HT) versus control subjects.

MATERIALS AND METHODS

The study included 33 healthy volunteers with normal ultrasound and laboratory findings and 70 patients with HT based on laboratory and sonographic findings who were undergoing follow-up and receiving medical treatment. HT patients were classified based on the modification of the scheme proposed by Sostre and Reyes that incorporates the extent of hypoechoic foci or patchy infiltration as grade A (foci involving <50% of the gland) and B (foci involving >50% of the gland). Thyroid volume, mean resistive indices, peak-systolic and end-diastolic velocities based on Doppler imaging, and vascularity index via superb microvascular imaging were obtained using a Canon Aplio 500 ultrasound device using a linear 10-14 MHz transducer.

RESULTS

Patients with HT had significantly higher median thyroid volume and peak-systolic velocities (7.32 ml and 19 cm/s, respectively) compared to control subjects (4.62 ml and 16 cm/s, respectively). HT patients had significantly higher median vascularity index (VI; 13.5%) compared to control subjects (7.95%). A significant fair positive correlation with VI and anti-thyroglobulin antibody levels (r=0.356, p<0.05) and significant moderate positive correlation with VI and anti-thyroid peroxidase antibody levels (r=0.503, p<0.05) were found. In HT diagnosis, the optimal VI cut-off value was 10.58% with a sensitivity and specificity of 67.1% and 90%, respectively.

CONCLUSION

Superb microvascular imaging appears to allow assessment of subtle vascularity changes in early HT stages that cannot be detected by Doppler parameters. This technique demonstrates excellent visualization of the microvascular structures and quantitative assessment based on a novel parameter such as VI.

Primary Rhabdomyosarcoma of the Breast: Imaging Findings and Literature Review

Background

Primary breast rhabdomyosarcoma (RMS) can occur in children. There is a lack of knowledge regarding radiologic findings and added diffusion-weighted magnetic resonance imaging (MRI) features of RMS in the literature.

Case Report

A 12-year-old girl was diagnosed with primary alveolar RMS of the breast. Gray scale ultrasound revealed posterior acoustic enhancement behind a well-circumscribed, multilobulated hypoechoic mass. Doppler ultrasound revealed increased peripheral and central vascularity. Hypointense septations on T2-weighted image exhibiting more enhancement than the stroma on late gadolinium-enhanced images were striking within a hyperintense mass. A hyperintense hemorrhagic focus on T1-weighted image was present in the absence of any necrosis. Avid enhancement on early postcontrast images proceeding from the periphery to the center was depicted.

Conclusion

A rapidly enlarging mass with an echogenic peripheral rim together with posterior acoustic enhancement on gray scale ultrasound, intense vascularity on Doppler ultrasound, axillary lymphadenopathy, and satellite nodules on MRI should raise suspicion. Enhancing central and peripheral septations are suggestive of RMS. Dynamic contrast-enhanced MRI in suspected cases can provide valuable data in the differential diagnosis.

Diagnostic performances of superb microvascular imaging, shear wave elastography and shape index in pediatric lymph nodes categorization: a comparative study

OBJECTIVE

To determine the diagnostic utility of a vascularity index via superb microvascular imaging in lymph nodes of children with malignant lymphoma and acute lymphadenitis compared to normal lymph nodes.

METHODS

We performed a retrospective study for multiparametric lymph node (LN) evaluation. Malignant lymphoma diagnosed via histopathological examination and lymph nodes receiving an acute lymphadenitis diagnosis based on clinical and laboratory findings constituted the study subgroups. We calculated a shape index [SI (percent of shortest to longest diameter)] using grayscale ultrasonography and elasticity and velocity values via shear wave elastography (SWE) as well as a vascularity index (VI) using superb microvascular imaging (SMI) for comparison with normal lymph nodes.

RESULTS

45 lymph nodes diagnosed with malignant lymphoma, 72 lymph nodes diagnosed with acute lymphadenitis and 146 normal lymph nodes were evaluated. For differentiating lymphoma from normal lymph nodes, vascularity index cut-off values higher than 15% represented a diagnostic accuracy of 95%; cut-off elasticity values higher than 17 kPa exhibited a diagnostic accuracy of 99%. Optimal VI, elasticity, velocity and SI cut-off values in differentiating lymphoma from lymphadenitis were 15%, 17 kPa, 2.45 m sn^-1 (p < 0.001) and 65% (p < 0.002) with calculated diagnostic accuracies of 83, 87, 88 and 68%, respectively.

CONCLUSION

Vascularity index values obtained via superb microvascular imaging and SWE would be reasonably useful in differentiating malignant lymphoma and acute lymphadenitis from normal LNs. SWE would be more efficient in distinguishing malignant lymph nodes from acute lymphadenitis compared with superb microvascular imaging. Advances in knowledge: Vascularity index by superb microvascular imaging would be a novel Doppler parameter in differentiating both lymphoma from lymphadenitis and also lymphadenitis from normal lymph nodes.

Evaluation of parotid glands in healthy children and adolescents using shear wave elastography and superb microvascular imaging

OBJECTIVES

We aim to determine parotid gland elasticity values from healthy children and adolescents using shear wave elastography (SWE). We also define the degree of vascularity using superb microvascular imaging (SMI), power Doppler (PD), and color Doppler (CD) and compare SMI with CD and PD.

MATERIALS AND METHODS

A total of 100 cases, comprising 50 girls and 50 boys, with ages ranging from 3 to 17 years were included in this prospective study. SWE, SMI, PD, and CD measurements were taken from both parotid glands, and the relationships with sex, age, and body mass index (BMI) were determined. The SMI was compared with the PD and CD.

RESULTS

The median elasticity values measured with SWE were 8.37 ± 2.09 kPa and 1.68 ± 0.26 m/s on the right and 8.33 ± 2.04 kPa and 1.69 ± 0.26 m/s on the left. There were significant positive correlations present for those aged below and above 10 years and for BMI with elasticity values. The median vascular spot numbers measured using SMI, PD, and CD were 5 ± 1.70, 3.5 ± 1.45, and 2 ± 1.1 on the right and 4 ± 1.7, 4 ± 1.43, and 2 ± 1.05 on the left, respectively. The median values obtained with SMI were significantly higher than the median values obtained with both PD and CD.

CONCLUSION

This study determined the reference SWE, SMI, PD, and CD values for normal parotid glands in healthy children and adolescents. Elasticity values were affected by age and BMI. There was no correlation between vascularity values and age, sex, or BMI. SMI provided more detailed information about vascularity compared with the other methods.

Giant Renal Hemangioma in an Adolescent Girl: A Very Rare Entity

Hemangiomas are benign vascular tumors of childhood and they usually tend to be located in the upper parts of the body (head and neck). However, renal hemangiomas are very rare and usually occur to be small (1-2 cm) in size. Here, we report an adolescent girl with a giant renal hemangioma of 15 cm diameter.

Coeliac trunk and common hepatic artery variations in children: an analysis with computed tomography angiography

BACKGROUND

Understanding the coeliac trunk (CeT) and hepatic artery anatomy is important not only in preventing iatrogenic injuries but also in planning surgical procedures in children. Therefore, the aim of this study is to analyse the prevalence of CeT and common hepatic artery (CHA) variations in the paediatric population.

MATERIALS AND METHODS

One hundred and seventy-four children who underwent abdominal multidetector computed tomography (MDCT) angiography, either because of trauma or liver transplantation, were analysed retrospectively. The patterns of CeT, CHA and their variant branches were revealed and compared with previous studies involving adults.

RESULTS

A total of 157 (90.2%) of the 174 patients had normal CeT anatomy, whereas 17 (9.8%) had variations. Five types of CeT variations were identified according to Song's classification in which 'hepatosplenic trunk + left gastric artery + superior mesenteric artery' was the most prevalent. One hundred-twelve (64.4%) of the 174 patients had normal CHA anatomy; however, 62 (35.6%) had variations. Six types of CHA variations were identified according to Michel's and Hiatt's classification. The most common was 'replaced left hepatic artery originating from left gastric artery'.

CONCLUSIONS

The prevalences of CeT and hepatic artery variations are high in children, as they are in older patients. Awareness of these variations is important in terms of avoiding iatrogenic injury and in promoting surgical procedure planning for liver transplantation or abdominal tumour surgery.

Bilateral Cystic Adrenal Neuroblastoma with Cystic Liver metastasis

Bilateral congenital cystic adrenal neuroblastoma (NB) with cystic liver metastasis is a very rare condition and only few cases have been reported in the literature. Herein we report a case of a congenital bilateral cystic adrenal NB with cystic liver metastasis and briefly discuss characteristic imaging features of cystic NB.

Acoustic radiation force impulse (ARFI) elastography in the evaluation of renal parenchymal stiffness in patients with ureteropelvic junction obstruction

PURPOSE

To investigate the role of acoustic radiation force impulse (ARFI) elastography in the detection of renal parenchymal damage in kidneys with and without ureteropelvic junction obstruction (UPJO).

METHODS

Twenty-five pediatric patients with a diagnosis of UPJO who underwent surgery and 15 pediatric patients with conservatively managed UPJO were prospectively evaluated with ARFI elastography. Sixteen healthy volunteers constituted the control group. Shear wave velocity (SWV) measurements in the upper, mid, and lower poles of the affected kidney were performed. SWV values of kidneys based on presence of UPJO and hydronephrosis grade were compared. The correlation of SWV values with residual renal function obtained from diethylenetriaminepentaacetic acid or mercaptoacetyltriglycine-3 renal scan was evaluated.

RESULTS

Significantly, higher SWV values were found in control kidneys compared to kidneys affected by UPJO. The median SWVs were 2.82 (2.51-3.07) m/s for the control kidneys and 2.36 (2.09-2.53) m/s for the kidneys in the UPJO group (p < 0.001). When UPJO patients were grouped according to the grade of hydronephrosis, grade 0 hydronephrotic kidneys [2.35 (2.11-2.50) m/s] and grade 3-4 hydronephrotic kidneys [1.86 (1.96-2.25) m/s] had significantly lower SWV values compared to grade 1-2 hydronephrotic kidneys [2.62 (2.37-2.90) m/s] (p < 0.05).

CONCLUSIONS

ARFI as a noninvasive, radiation-free procedure for evaluating parenchymal stiffness may prove useful in the diagnostic work-up and follow-up of children with UPJO-induced renal disease.

Perianal Fistula With and Without Abscess: Assessment of Fistula Activity Using Diffusion-Weighted Magnetic Resonance Imaging

Background:

Magnetic resonance imaging (MRI) is highly accurate for the depiction of both the primary tract of fistula and abscesses, in patients with perianal disease. In addition, MRI can be used to evaluate the activity of fistulas, which is a significant factor for determining the therapeutic strategy.

Objectives:

This study aimed to determine the usefulness of diffusion-weighted (DW) MRI for assessing activity and visibility of perianal fistula.

Patients and Methods:

Fifty-three patients with 56 perianal fistulas were included in the current retrospective study. The T2-weighted imaging (T2WI) and DWMRI were performed and apparent diffusion coefficient (ADC) values of fistulas were measured. Fistulas were classified into two groups: only perianal fistulas and fistulas accompanied by abscess. Fistulas were also classified into two groups, based on clinical findings: positive inflammatory activity (PIA) and negative inflammatory activity (NIA).

Results:

Mean ADC value (mm²/s) of PIA group was significantly lower than that of NIA group, regarding lesions in patients with abscess-associated fistulas (1.371 × 10^-3 ± 0.168 × 10^-3 vs. 1.586 × 10^-3 ± 0.136 × 10^-3; P = 0.036). No statistically significant difference was found in mean ADC values between PIA and NIA groups, in patients with only perianal fistulas (P = 0.507). Perianal fistula visibility was greater with combined evaluation of T2WI and DWMRI than with T2WI, for two reviewers (P = 0.046 and P = 0.014).

Conclusion:

The DWMRI is a useful technique for evaluating activity of fistulas with abscess. Perianal fistula visibility is greater with combined T2WI and DWMRI than T2WI alone.

Successful management of hepatic mucormycosis in an acute lymphoblastic leukaemia patient: a case report and review of the literature

We present a case of hepatic mucormycosis in a 9-year-old boy with acute lymphoblastic leukaemia. Despite long-term use of combined liposomal amphotericin B and posaconazole therapy, the lesion persisted and could only be treated by surgical excision. After surgery, antifungal treatment was continued with posaconazole. On follow-up, the patient had two episodes of ascending cholangitis which were responsive to intravenous antibiotics. He is doing well at the moment in remission for 2.5 years. Mucormycosis was long regarded as a fatal infection with poor prognosis. With early medical and surgical management, survival rates increase. Isolated hepatic mucormycosis is rare and only seven cases were reported in the literature up to now. We wanted to emphasise the role of early surgery in patients with hepatic mucormycosis in view of the literature.

Relative proportions of stromal to cellular components of pleomorphic adenomas: determination with shear wave elastography

OBJECTIVES

The purpose of this study was to evaluate whether the relative proportions of stromal to cellular components of pleomorphic adenomas have an effect on the shear elastic modulus determined by shear wave elastography (SWE).

METHODS

This study was approved by the Ethics Committee of our institution and performed between September 2011 and December 2012. Thirty-five patients who underwent surgery for a parotid mass were included in the study. The maximum shear elastic modulus of the mass was measured by SWE. Pleomorphic adenomas were histopathologically subdivided into stroma-poor, intermediate-stroma, and stroma-rich tumors based on the relative proportion of stromal to cellular components.

RESULTS

The maximum shear elastic modulus values of the pleomorphic adenomas ranged from 12.6 to 291.9 kPa (mean ± SD, 120.9 ± 92.8 kPa). The Friedman test revealed a statistically significant relationship between the stromal amount and maximum shear elastic modulus (P < .001). Stroma-poor adenomas (mean, 32.3 ± 27.7 kPa; range, 12.6-81.1 kPa) were softer on SWE than stroma-rich adenomas (mean, 174.1 ± 48.4 kPa; range, 92.7-217.2 kPa; P = .009). No such significant difference was detected between stroma-poor and intermediate-stroma tumors (mean, 146.3 ± 106.1 kPa; range, 19.1-291.9 kPa; P = .062) or between intermediate-stroma and stroma-rich tumors (P = .465).

CONCLUSIONS

Shear wave elastography depicts pleomorphic adenomas with a variable appearance, which is due to the relative proportions of stromal to cellular contents in the tumors.

Subserosal leiomyoma of uterus mimicking an ovarian tumor in adolescent patient

Uterine leiomyomas are the most common gynecological tumors in adult women. These benign tumors are rarely seen in the adolescent population: there are only a few cases that have been reported so far in this age group. In this case report, we present a giant uterine leiomyoma that mimicked an ovarian tumor in a 15-year-old girl.

Anterior mediastinal lymphangioma: pre- and postnatal sonographic findings

Anterior mediastinal lymphangiomas are very rare in utero with only a few cases reported in literature. We present a case of anterior mediastinal lymphangioma that was diagnosed on prenatal sonography (US) at 22 weeks' gestation. It appeared as a well-defined, multi-septated anechoic mass, in the anterior mediastinum between the heart base and right chest wall. There was no solid component and no internal flow on color Doppler US. The pre- and postnatal US findings are correlated with prenatal MRI and postnatal CT findings.

Intraabdominal extrapulmonary sequestration diagnosed by color doppler ultrasound at 22 weeks' gestation

Intraabdominal extrapulmonary sequestration is seen very rarely. When a left suprarenal mass is detected in prenatal sonography, vascularization of the lesion should be evaluated with color Doppler sonography. We present a case of intraabdominal extrapulmonary sequestration that was diagnosed by color Doppler ultrasound at 22 weeks' gestation.

Coronary events and anatomy after arterial switch operation for transposition of the great arteries: detection by 16-row multislice computed tomography angiography in pediatric patients

The purpose of this study was to evaluate the feasibility of multislice computed tomographic (MSCT) angiography as a noninvasive method for detecting ostial, proximal, and middle segment coronary stenosis or occlusion and anatomy in patients with transposition of the great arteries who had undergone arterial switch operation (ASO). Sixteen-detector-row MSCT angiography was performed in 16 patients treated with ASO for transposition of the great arteries. The median age was 10.3 years (range, 6.2-16.3 years). Sixteen-detector-row MSCT angiography was performed in 16 patients who had undergone ASO. CT imaging was performed in the craniocaudal direction from 2 cm above the carina up to the heart basis. Noninvasive assessment of coronary artery stenosis and anatomy were investigated by MSCT angiography. Two patients were excluded from the study because of artifacts. Of 14 evaluated patients, 1 patient had ostial stenosis (7.1%). A coronary artery anatomy variant was present in six patients: left main artery (LMA) and right coronary artery (RCA) originating from the right sinus as a single orifice (n = 2); left circumflex artery (LCX) originating from the RCA (n = 1); LMA and RCA, after branching to the LCX, originating separately from the right sinus (n = 1); and LMA (n = 1) and left anterior descending artery (LADA; n = 1) originating directly from the right sinus. Intramural bridging in the LAD (n = 2) was detected. Five patients were normal. In conclusion, MSCT angiography, as a noninvasive, feasible technique for assessing coronary stenosis or occlusion and anatomy, can be used in the follow-up of patients who have undergone ASO.

Isolated bone marrow natural killer cell lymphoma with central nervous system involvement mimicking a cerebral infarct

BACKGROUND

We describe the case of an isolated bone marrow natural killer (NK) cell lymphoma with central nervous system (CNS) involvement mimicking a cerebral infarct. CNS involvement in isolated bone marrow lymphoma has not been reported previously.

CASE REPORT

A 49-year-old man with complaints of fever, confusion, and agitation was presented. A bone marrow biopsy was performed to investigate the etiology of bicytopenia which was consistent with NK-cell lymphoma. Brain MRI findings were suggestive of a subacute infarct.

CONCLUSION

Even if pathological signal changes of the brain without contrast enhancement resembling infarct are detected in patients with lymphoma on the magnetic resonance imaging, CNS involvement of the lymphoma should be kept in mind in the differential diagnosis.

A case-control study of non-alcoholic fatty liver disease in breast cancer

BACKGROUND

Patients with breast cancer sometimes present with increased liver enzymes during follow-up period that may be consistent with hepatic steatosis. This effect known as non-alcoholic fatty liver disease may be associated with the malignancy itself, drugs or some other well-known risk factors that may induce steatosis. We studied the influences of primary disease and treatment on steatosis in patients with breast cancer.

MATERIALS AND METHODS

There were four groups of patients in our study. Group 1: 40 newly diagnosed, previously untreated breast cancer; Group 2: 45 cases of breast cancer treated with systemic therapy; Group 3: 40 cases of ovarian cancer; Group 4: 40 healthy women. Hepatic steatosis was evaluated by sonography by two radiologist, independently. We also evaluated major risk factors, biochemical findings, and influences of treatment on hepatic steatosis.

RESULTS

We detected steatosis in 63%, 72%, 77%, and 48% of patients in groups 1, 2, 3, and 4, respectively. There was a statistically significant difference only between groups 3 and 4 (P = 0.045). However, grade 2 and 3 steatosis were more frequent in breast cancer patients (group 1 and 2), compared with mild steatosis in ovarian cancer patients and healthy women. Although a good correlation was found between tamoxifen use and chemotherapy on development of non-alcoholic fatty liver disease, no association of hepatic steatosis with transaminase levels was found, which might be of help for earlier detection of steatosis. AST/ALT ratio was found to have no impact on the rate of hepatic steatosis, contrary to the literature.

CONCLUSION

Hepatic steatosis, excluding patients with grade 1 steatosis, which may be a normal variant, were more readily detected in patients with breast cancer. This effect was aggravated by use of tamoxifen, but not the chemotherapy. Non-alcoholic fatty liver disease in patients with breast cancer may be associated with the primary tumor itself or some well-known risk factors such as obesity, hyperlipidemia, and diabetes mellitus, which needs to be explored.

Lumbosacral osseous tumors in children

A wide variety of benign and malignant neoplasms in children involve the lumbosacral region. When a solitary lesion of the lower spine occurs, tumors or tumor-like lesions represent an important group of entities for diagnostic consideration. Diagnostic investigation should begin with a patient history, physical examination, laboratory testing, and radiography. Roentgenograms, which demonstrate bone deviations, should be used as an initial examination. The results should direct further imaging studies, such as computed tomography (CT), magnetic resonance imaging (MRI), and bone scintigraphy. CT should be the chosen modality for delineating tumoral osteoid matrix formation. MRI shows soft-tissue masses and medullary infiltration better than any other radiological modality. A multimodal radiological approach is helpful in the overall evaluation and differential diagnosis of vertebral lesions in children. Although imaging features, especially of benign lesions, may yield a high percentage of accurate diagnoses, in cases with radiological findings highly suggestive of malignancy, a specific diagnosis cannot always be made, and histopathological findings are essential to achieve the diagnosis that will guide the therapy.

Extrahepatic abdominal hydatid disease caused by Echinococcus granulosus: imaging findings

OBJECTIVE

The classical findings in hydatid disease caused by Echinococcus granulosus with liver or lung involvement are well known. However, diagnosing hydatid disease at unusual locations may be challenging because of variable imaging appearances depending on the host reaction. The purpose of this pictorial essay is to review the sonographic, CT, and MRI features of extrahepatic abdominal hydatid disease including intraperitoneum, retroperitoneum, diaphragma, bone, and soft tissue of the abdomen.

CONCLUSION

Extrahepatic abdominal hydatid lesions have nearly identical imaging features, including the presence of cyst wall calcification, daughter cysts, and membrane detachment. The combinations of radiologic and serologic tests especially in patients living in the endemic areas contribute to the diagnosis. Despite their rarity, being familiar with the spectrum of radiologic findings in these unusual sites is helpful to improve diagnostic accuracy.

Pseudocoarctation

Pseudocoarctation, also known as kinking or buckling of the aorta, is an uncommon anomaly. Its recognition is important, because it may be mistaken for true coarctation, aneurysm or mediastinal neoplasm. A case of pseudocoarctation associated with left cervical aorta is reported. The present case is unique in the demonstration of obvious tortuosity and kink formation of the cervical aorta and main branches without frank aneurysm formation. Magnetic resonance angiography as a noninvasive imaging modality was suggested for the definitive diagnosis of cervical aortic arch and its accompanying anomalies.

Enteroclysis in older children and teenagers

BACKGROUND

Enteroclysis (EC) has been widely and successfully used for evaluation of the small bowel in adults for about 30 years. However, despite recently improved intubation and examination techniques, in many paediatric radiology centres it is still not the preferred conventional barium study for the evaluation of small bowel pathology in children.

OBJECTIVE

To share our 10 years of experience and review the feasibility of EC in 83 older children and teenagers, in terms of both technique and pathological findings.

MATERIALS AND METHODS

Between 1996 and 2006, EC was performed by the standard technique described by Herlinger to 83 children between 7 and 18 years of age. The indication for the study was jointly decided by the paediatric radiologist and the clinician. None of the examinations was converted to follow-through studies because of patient refusal or technical failure. Morphological changes, mucosal abnormalities, luminal abnormalities, perienteric structures, the location of the disease, indirect findings regarding the bowel wall and functional information were evaluated.

RESULTS

All the children tolerated the procedure without difficulty. Out of 83 patients, 63 had abnormal findings. The spectrum of diagnoses were Crohn disease (n = 23), nonspecific enteritis (n = 10), malabsorption (n = 8), intestinal tuberculosis (n = 6), intestinal lymphoma (n = 5), Peutz-Jegher syndrome (n = 3), adhesions (n = 2), Behçet disease (n = 2), back-wash ileitis due to ulcerative colitis (n = 2), common-variable immune deficiency (n = 1) and lymphangiectasis (n = 1).

CONCLUSION

EC can easily be performed in children over 7 years of age and when performed using a correct technique it shows high diagnostic performance without any complications in the evaluation of small bowel diseases in older children and teenagers.

Pain & resistance in patients with adhesive capsulitis during contrast material injection phase of MR arthrography

BACKGROUND & OBJECTIVE

Adhesive capsulitis of the shoulder is a condition of unknown aetiology that results in the development of restricted active and passive glenohumeral motion. It has been reported that magnetic resonance (MR) imaging is useful in diagnosing adhesive capsulitis. We carried out this study to assess how pain and/or resistance during contrast material injection affects the diagnosis of adhesive capsulitis on magnetic resonance (MR) arthrography.

METHODS

The study included MR arthrography examinations of 21 patients with a diagnosis of adhesive capsulitis. The control group consisted of 20 patients who presented clinically with rotator cuff tear. The pain (visual analog scale, VAS), resistance to injection and the amount of contrast material that could be injected during injection phase of MR arthrography was assessed and compared between groups.

RESULTS

The patients in adhesive capsulitis group (mean VAS score 66.5+/-25.5) experienced more pain when compared with the control group (mean VAS score 34.9+/-27.7, P<0.001). A statistically significant difference (P<0.001) in terms of the amount of the injected fluid (4.3+/-2.6 ml for adhesive capsulitis group, and 10.9+/-4.1 ml for control group) was seen into the joint cavity. Resistance to injection was significantly more (P<0.001) in patients with adhesive capsulitis when compared to control group.

INTERPRETATION & CONCLUSION

Experience of pain during injection, a decreased amount of contrast material injected and resistance to injection in patients during injection phase of MR arthrography may suggest adhesive capsulitis.

Utilization of low-dose multidetector CT and virtual bronchoscopy in children with suspected foreign body aspiration

BACKGROUND

Foreign body aspiration is common in children, especially those under 3 years of age. Chest radiography and CT are the main imaging modalities for the evaluation of these children. Management of children with suspected foreign body aspiration (SFBA) mainly depends on radiological findings.

OBJECTIVE

To investigate the potential use of low-dose multidetector CT (MDCT) and virtual bronchoscopy (VB) in the evaluation and management of SFBA in children.

MATERIALS AND METHODS

Included in the study were 37 children (17 girls, 20 boys; age 4 months to 10 years, mean 32 months) with SFBA. Chest radiographs were obtained prior to MDCT in all patients. MDCT was performed using a low-dose technique. VB images were obtained in the same session. Conventional bronchoscopy (CB) was performed within 24 h on patients in whom an obstructive abnormality had been found by MDCT and VB.

RESULTS

Obstructive pathology was found in 16 (43.25%) of the 37 patients using MDCT and VB. In 13 of these patients, foreign bodies were detected and removed via CB. The foreign bodies were located in the right main bronchus (n = 5), in the bronchus intermedius (n = 6), in the medial segment of the middle lobe bronchus (n = 1), and in the left main bronchus (n = 1). In the remaining three patients, the diagnosis was false-positive for an obstructive pathology by MDCT and VB; the final diagnoses were secretions (n = 2) and schwannoma (n = 1), as demonstrated by CB. In 21 patients in whom no obstructive pathology was detected by MDCT and VB, CB was not performed. These patients were followed for 5-20 months without any recurrent obstructive symptomatology.

CONCLUSIONS

Low-dose MDCT and VB are non-invasive radiological modalities that can be used easily in the investigation of SFBA in children. MDCT and VB provide the exact location of the obstructive pathology prior to CB. If obstructive pathology is depicted with MDCT and VB, CB should be performed either for confirmation of the diagnosis or for the diagnosis of an alternative cause for the obstruction. In cases where no obstructive pathology is detected by MDCT and VB, CB may not be clinically useful.