Real-time elastography in the diagnosis of prostate tumor.

AIM: To assess the diagnostic gain of transrectal real-time elastography (RTE) compared to transrectal B-mode ultrasonography (US) in the detection of tumors in patients suspected of having prostate cancer. MATERIALS AND METHODS: Eighty-four patients suspected of having prostate cancer on the basis of clinical and biochemical evaluation underwent transrectal US, RTE and transperineal prostate biopsy. RESULTS: Biopsy was considered the gold standard. Analysis related to the total number of patients showed a B-mode US sensitivity of 56%, specificity 80%, positive predictive value (PPV) 70% and negative predictive value (NPV) 67%. Analysis related to the total number of biopsy cores showed sensitivity 33%, specificity 92%, PPV 69% and NPV 73%. In the patient-related analysis, RTE sensitivity was 51%, specificity 75%, PPV 64% and NPV 64%, while the core-related analysis showed sensitivity 36%, specificity 93%, PPV 72% and NPV 74%. Comparison of B-mode US and RTE diagnostic accuracy in the detection of tumors located in the peripheral zone of the prostate gland showed a significant difference. Analysis related to the total number of biopsy cores harvested in the peripheral zone of the prostate gland showed a B-mode US sensitivity of 48%, specificity 81%, PPV 75% and NPV 58%, whereas RTE achieved the following values: sensitivity 66%, specificity 78%, PPV 77%, and NPV 67%. CONCLUSIONS: RTE is a valid addition to B-mode US, and RTE reached a higher accuracy than B-mode US in the evaluation of the peripheral zone of the prostate gland and in the selection of appropriate biopsy sites.

Ultrasound examination using contrast agent and elastosonography in the evaluation of single thyroid nodules: Preliminary results.

AIM: To evaluate the usefulness of ultrasound (US) using contrast agent and elastosonography in the characterization of thyroid nodules. MATERIALS AND METHODS: From November 2006 to July 2007, 23 patients with single thyroid nodules underwent B-mode US and power Doppler, US examination using contrast agent, elastosonography and fine needle aspiration cytology (FNAC). Sixteen patients underwent thyroidectomy. RESULTS: The 23 nodules included 14 benign and 9 malignant lesions. Analysis of time/intensity curves showed that wash-in (8.8 ± 1.3 vs 12.1 ± 2.6 s; p = 0.002, t-test) and peak enhancement (15.3 ± 4.6 vs 22.2 ± 3.9 s; p = 0.001, t-test) occurred significantly earlier in the malignant nodules than in the benign nodules. Wash-out was monophasic in 70% of benign nodules, but in none of the malignant nodules; polyphasic in 30% of benign nodules and in 100% of malignant nodules. Polyphasic wash-out showed a statistically significant association with malignancy (p = 0.0007, χ(2)). Polyphasic wash-out yielded a sensitivity of 100%, specificity of 71%, positive predictive value (PPV) of 69%, negative predictive value (NPV) of 100% and diagnostic accuracy of 83%. In 78% of the benign nodules (11/14) elastosonographic patterns was 1-2 (elevated elasticity); in 88% of the malignant nodules (8/9) elastosonographic patterns was 3-4 (reduced elasticity). Elastosonography yielded a sensitivity of 88%, specificity of 78%, PPV of 72%, NPV of 91% and diagnostic accuracy of 82%. Elastosonographic patterns 3-4 is associated with malignancy (p = 0.001, χ(2)). CONCLUSION: US using contrast agent and elastosonography can be a useful diagnostic tool in the evaluation of single thyroid nodules, particularly when FNAC result is non-diagnostic or suggests a follicular lesion, and in nodules <1 cm.

Treatment of small HCC through radiofrequency ablation and laser ablation. Comparison of techniques and long-term results.

PURPOSE: The aim of this trial was to compare the results obtained using laser ablation (LA) and radiofrequency ablation (RFA) to treat small hepatocellular carcinomas (HCC). MATERIALS AND METHODS: From 2003 to 2005, a total of 81 cirrhotic patients (59 Child-Pugh A, 22 Child-Pugh B) presenting a total of 95 HCC nodules (mean diameter 27.9 mm) were treated with LA (41) and RFA (40). RESULTS: Computed tomography (CT) revealed complete tumour ablation in 78% of nodules treated with LA and in 94% of those treated with RA; the disease-free interval was 16.50+/-8.1 months. The cumulative survival rates were 91.8%, 59% and 28.4% at 12, 36 and 60 months, respectively. The patients treated with RFA had better survival rates than those treated with LA, although this difference was not statistically significant (p=0.3299). Univariate analysis of survival revealed statistically significant differences between the Child-Pugh A and B groups (p<0.0001), between HCC nodules measuring < or =25 mm and >25 mm (p=0.0001) and between patients with a single nodule and with two nodules (p=0.0484). CONCLUSIONS: We found LA and RFA to be equally effective. However, RA appears more suited to patients with small HCC nodules and in Child-Pugh class A.

Ultrasound and magnetic resonance imaging in sports-related muscle injuries.

PURPOSE: The objective of this study was to evaluate the role of magnetic resonance imaging (MRI) and ultrasonography (US) in the diagnosis of traumatic muscle injuries. MATERIALS AND METHODS: From June 2003 to June 2004, 81 football players with a history of traumatic muscle injuries to the lower limbs were examined. US was performed shortly after the trauma (from 6 to 72 h afterwards) and MRI within a maximum of 5 days. RESULTS: MRI revealed 26 minor and 55 major traumas. MRI and US showed complete concordance in 71 patients (site, type and extent of injury). US produced ten false negative results, including six minor lesions and four major lesions. US had a sensitivity of 87.65% in the correct identification of muscle injuries; its sensitivity was 92.72% for major lesions and 76.92% for minor lesions, 57% for delayed-onset muscle soreness (DOMS), 80% for lengthenings, 83% for contractures, 84% for strains, 87.5% for mild contusions and 100% for severe contusions. CONCLUSIONS: US is the first-line technique for examination of muscle injuries. MRI is able to reveal lesions that may be missed at US and provide a more accurate assessment of site and extent of injury.

Transrectal colour Doppler contrast sonography in the diagnosis of local recurrence after radical prostatectomy--comparison with MRI.

OBJECTIVE: To assess the usefulness of colour power-Doppler transrectal sonography before/after contrast agent in the detection of local recurrence in patients with rising prostate-specific antigen values after radical prostatectomy and to compare with magnetic resonance imaging . MATERIALS AND METHODS: 18 patients with rising prostate-specific antigen values after prostatectomy underwent digital rectal examination, bone scintigraphy, magnetic resonance imaging, transrectal colour power-Doppler sonography before/after contrast agent, and transrectal sonography-guided biopsy. Sensitivity, specificity, accuracy, positive and negative predictive values were calculated. Results were correlated using McNemar binomial 2-tailed P-test. RESULTS: Baseline and contrast-enhanced transrectal colour power-Doppler sonography and contrast-enhanced magnetic resonance imaging identified recurrent disease in 6, 10 and 10 patients, respectively. Biopsy confirmed recurrence in 10 patients, but was positive also in 2 additional patients who were negative at contrast-enhanced transrectal colour power-Doppler sonography and contrast-enhanced magnetic resonance imaging. The remaining 6 patients were negative also at diagnostic imaging and biopsy after 30 days. Grey-scale transrectal sonography values were: sensitivity 91.7 %, specificity 66 %, PPV 91.6 %, NPV 40 %. Baseline colour power-Doppler transrectal sonography values were: sensitivity 38.5 %, specificity 85 %, diagnostic accuracy 50 %, PPV 83.3 %, NPV 33.3 %. Contrast enhanced colour power-Doppler transrectal sonography and magnetic resonance imaging values were: sensitivity 76.9 %, specificity 100 %, diagnostic accuracy 83.3 %, PPV 100 %, NPV 62.5 %. CONCLUSION: Contrast-enhanced transrectal colour power-Doppler sonography increases specificity in the detection of local recurrence after prostatectomy. Magnetic resonance imaging yields equivalent accuracy. Biopsy remains the diagnostic gold standard, but the use of imaging methods may reduce the number of biopsies.

[Computerized tomography of the meniscus with a stress device]. / Studio con Tomografia Computerizzata dei menischi con apparecchio distrattore.

PURPOSE: We investigated the usefulness of a mechanical stress device to increase widening of the articular rima in CT studies of the meniscus on forced varus and valgus. MATERIAL AND METHODS: September 1997 to October 1998, we examined 284 patients with symptoms and clinical signs of meniscal injury. CT was performed during forced varus and valgus, depending on the site of the suspected damage, in 70 of 284 patients. We used an FOV of 18 cm, with a potential difference of 140 kVp and power of 170 mA. The reconstruction matrix was 512 x 512 and acquisition time was 3 s. A set of 8-10 partially overlapping scans were acquired craniocaudally, with slice thickness of 1.5 mm and gap of 1 mm. The mechanical strainer was locked in the correct position and a second set of 4-5 images acquired at the meniscus. Then the patients were submitted to arthroscopy to check the radiological findings. RESULTS: CT performed in forced varus and valgus had 96.8% specificity, 97.3% sensitivity and 97.1% diagnostic accuracy. Sensitivity was 100%, specificity 96% and diagnostic accuracy 98% in the medial meniscus, while we had 88.9%, 100% and 94.7% respectively in the external meniscus. CONCLUSIONS: CT with a mechanical stress device was extremely useful in defining the meniscal loose edge. It also showed the exact shape and complexity of meniscal injury, even in the cases with narrow articular rima or those where conventional CT had performed poorly.

Adult colonic intussusception caused by malignant tumor of the transverse colon.

Adult colonic intussusception is rare and often originates from neoplasms. In emergency situations it can be difficult to diagnose. Our aim was to show how the integration of readily available diagnostic means in emergency situations can help in making a correct diagnosis of this disease. A 68-year old male patient presented with vomiting and abdominal pain. The abdomen was distended, with pain to palpation in the left quadrants without a mass. Plain radiographs of the abdomen showed a large amount of gas in the small bowel and in the right and transverse colon. A barium enema demonstrated an endoluminal filling defect in the descending colon. Abdominal ultrasonography revealed the presence of intraperitoneal fluid and thickened left colonic wall at the site of the lesion, with an aspect of a "double ring" consistent with intussusception. A solid formation was also revealed at a point distal to the thickened colonic wall. At emergency laparotomy an approximately 8-cm-long mass was palpable through the left colon. A colostomy was fashioned, and subsequently colonoscopy revealed the presence of a left colon tumor. At the subsequent operation an invagination of the left transverse colon into the descending colon was confirmed. The left transverse and descending colon were resected with high ligation of the left colic artery. Macroscopic examination of the invaginating head showed a vegetating transverse colon neoplasm. We conclude that in emergency settings the association of readily available diagnostic means such as plain abdominal radiography, water soluble contrast enema and ultrasonography may yield reliable information for diagnosing colonic intussusception.

[High-resolution ultrasonography in the study of carpal tunnel syndrome]. / L'ecografia con alta risoluzione nello studio della sindrome del tunnel carpale.

We investigated the reliability of some US signs in the diagnosis of the carpal tunnel syndrome. We carried out a single-blind study with 13-MHz high resolution probes and electromyography on 132 patients with clinical evidence of the carpal tunnel syndrome; a control group of 20 asymptomatic patients was also submitted to US. Eighty-six of 107 patients with US signs of the carpal tunnel syndrome were then submitted to surgical decompression (resection of the transverse carpal ligament), while the extant 21 patients underwent conservative treatment and clinical follow-up. To diagnose the carpal tunnel syndrome, we considered the following US patterns: median nerve changes (swelling before its entrance into the carpal tunnel and flattening in the tunnel itself), palmar bowing of the flexor retinaculum, thickening of the transverse carpal ligament and increased depth of the carpal tunnel, as measured from the apex of the transverse carpal ligament convexity to the underlying carpal bone. Median nerve changes were unreliable signs and were missing in many cases: only 45 of 107 patients exhibited median nerve swelling before and/or its flattening in the carpal tunnel (42%). Such indirect signs as the thickening of the transverse carpal ligament in chronic cases were demonstrated in 94 of 107 patients with the carpal tunnel syndrome (88%) and canal deepening in all unilateral carpal tunnel syndromes was shown in 92 of 107 patients (87%); both these signs proved to be much more reliable. The palmar bowing of the flexor retinaculum was also difficult to demonstrate in surgical patients or in those with connective tissue fibrosis within the tunnel: this sign was demonstrated in 80 of 107 patients with the carpal tunnel syndrome confirmed with electromyography (75%). Tanzer and Rietze reported median nerve changes observed at surgery in 43% and 66% of their patients, respectively. Recent MR findings in asymptomatic wrists have demonstrated that the normal median nerve has an elliptical shape inside the carpal tunnel. To conclude, high resolution US exhibited 96% sensitivity, 95% specificity and 93% diagnostic accuracy and proved to play a major role in the diagnosis of the carpal tunnel syndrome.

[Role of Doppler color in the differential diagnosis of benign and malignant adenopathies]. / Ruolo del color Doppler nella diagnosi differenziale delle adenopatie benigne e maligne.

The diagnosis of enlarged lymph nodes is of the utmost importance especially in the treatment planning of cancer patients. US yields such morphological findings as node size, longitudinal/transverse diameter ratio, hilum visibility and cortical thickness, which however do not permit the differential diagnosis of benign from malignant forms. Some authors tried to distinguish inflammatory enlargement from metastatic forms on the basis of color Doppler findings, with conflicting and questionable results. We investigated the potentials of color Doppler US in the differential diagnosis of benign and malignant lymph node enlargement using morphological data and flow measurements in lymphatic hilum vessels. The palpable superficial lymph nodes of 70 patients were studied with color Doppler with a linear probe (7.5-10 MHz) equipped for Doppler flow measurements. The largest lymph node was studied in multiple enlargement. The final diagnosis was made with US-guided cytology and/or excisional biopsy. The venous hilar vessels were depicted with color Doppler US in 44/45 patients with lymphadenitis and only in 1/17 patients with metastatic enlargement. Spectral Doppler exams of the hilar arteries showed flows with a wide telediastolic component in lymphadenitis (relative RI:0.58), while flow was rapid and with poor telediastolic component (relative RI:0.84) in metastatic enlargement. Average RI was 0.62 in Hodgkin's lymphomas and 0.71 in all the other lesions. We conclude that the distortion and compression of the main hilar vessels in metastatic lymph node enlargement often prevents color Doppler depiction of venous vessels. Moreover, the compression and distortion of the intranodal capillary network (the "mass" effect) often results in increased RI, as detected with power Doppler in the lymphatic hilum. Even though color Doppler US studies of the hemodynamic changes in the hilar vessels need further validation in larger series of cases, our preliminary results suggest interesting potentials in distinguishing inflammatory from metastatic enlargement, which differentiation remains nevertheless difficult especially in Hodgkin's lymphoma.

[Ileal occlusion with strangulation: importance of ultrasonography findings of the dilated loop with intraluminal fluid-fluid resulting from sedimentation]. / Occlusione ileale con strangolamento: importanza del segno ecografico dell'ansa dilatata con livello fluido-fluido intraluminale da sedimentazione.

To identify some dynamic or morphological patterns for the diagnosis of small bowel obstruction by hernia, adhesions or volvulus, we submitted to ultrasonography (US) 61 patients with clinical and radiographic syndromes of mechanical small bowel obstruction. The cause of obstruction was demonstrated in 58 patients-namely, with surgery in 56 patients and further instrumental examinations in 2. Three patients died before surgery. In our series, small bowel obstruction with strangulation was demonstrated at surgery in 31/56 patients. In 27/31 patients, US showed the coexistence of dilated loops with different kinetic behavior in the abdominal cavity-i.e., the simultaneous presence of akinetic loops with an intraluminal fluid-fluid level by sediment and peristaltic loops with solid particles in suspension. In 4/31 patients with strangulating small bowel obstruction. US provided no useful elements to explain the mechanism of obstruction. The US pattern of fluid-fluid levels due to intraluminal sediment in all the intestinal mass above the occluded segment was observed in 6/6 patients with uncompensated mechanical intestinal obstruction. This sign is due to the absence of intestinal muscular activity in the late stages of mechanical intestinal obstruction; its value is purely prognostic. To conclude, the US pattern of fluid-fluid levels by sediment diffused in the whole intestinal mass provides no useful elements to explain the cause of obstruction: on the contrary, the US pattern characterized by isolated intraluminal fluid-fluid levels or by the association of akinetic and peristaltic loops in the abdominal cavity appears pathognomonic of strangulating obstruction caused by volvulus, adhesion or hernia, with 87% sensitivity and 100% specificity.

[Interstitial photocoagulation with laser in the treatment of liver metastasis]. / La fotocoagulazione interstiziale con laser nel trattamento delle metastasi epatiche.

Interstitial laser photocoagulation (ILP) causes tumor necrosis with local hyperthermia produced by laser light energy. We treated with US-guided ILP 14 patients (7 men and 7 women; mean age: 67 years) and 20 metastases: 9 of them were < 3 cm in max. diameter and 11 were > 3 cm (mean diameter: 2.9 cm); 14 metastases were from colon carcinoma, 5 from breast cancer and 1 from lung cancer. ILP was performed with 300 and 600 microns quartz fiberoptic guides advanced in 21-18G Chiba needles and a continuous-wave Nd: YAG laser with 1064 nm wavelength. We used single expositions of 5-6 minutes with an irradiation power of 5 watts and scheduled 3 treatment sessions, performing CT scans and biopsies at the end of each session. The extent of induced necrosis was classified as follows on the basis of CT findings: grade 1 = 100% necrosis; grade 2 = necrosis > 50%; grade 3 = necrosis < 50%. The average follow-up was 6 months. After the 3 scheduled treatment sessions, CT showed grade 1 necrosis in all the lesions < 3 cm in diameter and in 4/9 (44%) lesions > 3 cm and grade 2 and 3 necrosis in the remaining cases (necrosis > 50% in 95% of the lesions and 92% of the patients). The cytologic findings were in agreement with CT results in all grade 2 and 3 cases, but in one grade 1 necrosis cytology showed residual viable tumor. To conclude, ILP is a safe and well-tolerated procedure. Maximum efficacy was observed in the lesions < 3 cm, while lesion volume was markedly reduced in the lesions > 3 cm. US is a useful tool in the real-time monitoring of this procedure and CT is the most accurate imaging technique to assess treatment efficacy.

[Color Doppler echography in the study of obstruction-related lung collapse]. / L'eco color Doppler nello studio delle atelettasie polmonari su base ostruttiva.

The typical US pattern of obstructive atelectasis consists in a triangular hypoechoic area with anechoic bands inside related to fluid-filled bronchial structures--the US fluid bronchogram sign. According to some authors, this US sign within a chest mass indicates pulmonary parenchyma disease. Furthermore, it suggests the diagnosis of lung collapse. Sixty-one patients with obstructive atelectasis confirmed with conventional radiography, conventional and computed tomography, and bronchoscopy were submitted to B-mode and color-Doppler US to assess the importance of the US fluid bronchogram sign in obstructive pulmonary atelectasis. In this condition, B-mode US showed tubular anechoic bands in 59/61 patients. Power Doppler venous sampling showed a Doppler spectrum with marked phase oscillations. Arterial sampling showed a Doppler spectrum with high distal impedance-with poor or totally absent diastolic component. To conclude, in the atelectasis area, B-mode US showed in 96% of patients some anechoic bands with no apparent pulsatility. Color-Doppler showed color flow in 100% of cases, which confirmed the vascular nature of the masses. Thus, the US fluid bronchogram, which is frequently described in the literature, was never observed in our series. Power Doppler spectral flow analysis can be useful in the diagnosis of obstructive atelectasis because it depicts the hemodynamics of atelectasis parenchyma. Indeed, the arterial spectrum with high distal resistance is consistent with the effects of hypoxia on intra-atelectatic blood vessels. Further research is necessary to assess the role of color-Doppler US in the hemodynamic study of intra-atelectatic vessels. However, our preliminary results open new perspectives for the acquisition of physiopathologic data on abnormal blood flow in obstructive atelectasis.

[Significance of the combination of small intestine enema and ultrasonography in the follow-up of Crohn's disease. Clinical correlations]. / Validità dell'associazione del clisma dell'intestino tenue e dell'ecotomografia nel follow-up della malattia di Crohn. Correlazioni cliniche.

High-resolution US yields important information for the study of Crohn's disease. A more accurate follow-up is possible by the integration of US with radiological and clinical findings. Sixty-two patients with suspected or known Crohn's disease were examined with double-contrast small bowel enema and high-resolution US. The latter allowed the demonstration of such pathologic findings as mesenteric thickness greater than 15 mm, submucosal thickness (third hyperechoic layer greater than 50% of total bowel wall thickness), lymphadenopathies, and fluid collections. The authors suggest that US grading be performed, and radiological correlations made. The combined use of the two techniques yields better results and allows a better assessment of the patients, which is very useful for both prognosis and therapy.

[Ultrasonography in the study of synovial disorders and tendon lesions in rheumatoid arthritis]. / L'ecografia nello studio delle alterazioni sinoviali e delle lesioni tendinee nell'artrite reumatoide.

Conventional radiology is the main diagnostic tool for the visualization of osteoarticular lesions in rheumatoid arthritis. Articular effusions and popliteal cysts were examined with US. This paper is aimed at proving US capabilities in yielding important information about articular and peri-articular soft tissues in the early phases of rheumatoid arthritis. Over the last 30 months, the shoulder, wrist, hand, knee, and hip of 73 rheumatoid patients were studied by means of US and conventional and microfocal radiography. The patients were divided into 2 groups according to the time of onset of the disease. In group A, US demonstrated early synovial exudative inflammation, whereas conventional and microfocal radiography mainly demonstrated soft tissue swelling. In group B (where the first onset dated back to over 1 year), US demonstrated exudative and proliferative changes, together with recurrences. The authors believe US to be able to recognize the early changes of rheumatoid arthritis: as a matter of fact, US shows articular and periarticular soft tissues abnormalities and allows a differential diagnosis to be made between exudative and proliferative forms.