Contrast Enhanced Ultrasound in CT-undetermined Focal Liver Lesions.

Purpose: The purpose of this study was to examine the diagnostic accuracy of CEUS in the diagnosis of focal liver lesions, which were undetermined at CT scan. Materials and Methods: From January 2010 to December 2010, patients with CT-undetermined focal liver lesions were included in this study. A total of 78 patients were evaluated: 41 men and 37 women, mean age 61.8 years; age range 30-91 years. All patients were examined with GE LOGIQ 9E ultrasound scanners with contrast-specific software, and SonoVue intravenous bolus. The standard of reference was composite consisting of: percutaneous biopsy, surgical resection, PET/CT and clinical follow-up. Results: The 78 included patients had 163 undetermined focal liver lesions, mean size 1.1 cm, range 0.1-5.3 cm. There were 18 malignant and 145 benign liver lesions, as defined by the standard of reference. In differentiating between benign vs. malignant CEUS demonstrated sensitivity, specificity, PPV, NPV and accuracy of 94.4% (95% CI: 56.3-99.5%), 99.3% (95% CI: 94.9 -99.9%), 94.4% (95% CI: 56.3-99.5%), 99.3% (95% CI: 94.9-99.9%) and 98.7% (95% CI: 94.9-99.7%), respectively. If the CEUS-inconclusive results were assumed to indicate malignancy, then sensitivity, specificity, PPV, NPV and accuracy would be 95.8% (95% CI: 66.4-99.6%), 98.6% (95% CI: 94.4-99.7%), 92.0% (95CI: 65.1-98.6%), 99.3% (95% CI: 95.0-99.9%), 98.2% (95% CI: 94.4-99.5%). Conclusion: The results of this study showed a high diagnostic accuracy for CEUS in undetermined focal liver lesions found by CT. Due to a high diagnostic accuracy of CEUS in this study, it was cautiously concluded that CEUS is useful in differentiating between malignant and benign focal liver lesions in clinical practice.

Ultrasound guided laser ablation of a parathyroid adenoma.

We present a case of primary hyperparathyroidism with severe hypercalcaemia, treated successfully with ultrasound (US) guided percutaneous interstitial laser photocoagulation (ILP) of a single parathyroid tumour. To our knowledge, this is the first reported case of ILP applied in primary hyperparathyroidism. US guided thermic tissue coagulation with ILP may be a non-surgical alternative in patients with symptomatic hypercalcaemia due to a parathyroid tumour when surgery is contraindicated.

US-guided fine needle aspiration versus coarse needle biopsy of thyroid nodules.

OBJECTIVE: The aim of this study was retrospectively to evaluate ultrasound (US) guided fine-needle aspiration (FNA), in combination with US-guided coarse-needle biopsies, (CNB) from solitary or dominant thyroid nodules routinely performed during a 2 year period. METHODS: Seventy seven patients were biopsied using US-guided FNA and CNB. FNA was performed using a 21-Gauge needle and CNB using a 18-Gauge single action spring-activated needle biopsy system. The biopsies were performed with local anaesthesia. The Department of Pathology routinely examined the biopsy specimens. The retrieval rate in obtaining material for diagnostic evaluation was FNA (97%), CNB (88%), FNA and CNB (100%). RESULTS: In all, 41 of the 77 patients underwent neck-surgery. The surgical specimens were used to determine the results of diagnosing neoplasia. The accuracy, sensitivity and specificity for FNA were 80, 83, and 77%. For CNB 86, 78, and 94%. For both FNA and CNB 80, 89 and 73%. The diagnostic value of the two methods showed no significant difference (P < 0.05). CNB revealed contrary to FNA, however, one additional cancer. Also a higher number of false positive findings was noticed using FNA. No serious complications were registered. Adequate biopsies were obtained in all the patients using the combination of US-guided FNA and CNB. No patient underwent rebiopsy. CONCLUSIONS: The study demonstrated that neither US-guided CNB nor the combination of US-guided FNA and CNB were superior to US-guided FNA. US-guided CNB is only recommended in few selected patients.

Impact of intraoperative ultrasonography on surgical treatment of liver tumours.

PURPOSE: The aim of this study was to evaluate the impact of intraoperative ultrasonography (IOUS) on surgical decision-making in patients with liver tumours. MATERIAL AND METHODS: IOUS of the liver was performed in 116 patients undergoing surgery for liver tumours. The patients were evaluated preoperatively by ultrasonography, CT and in some cases, by ERCP and scintigraphy. IOUS findings were compared with the results of preoperative imaging and surgical findings. RESULTS: The surgical procedures were altered in 50 cases (43%), extended in 19 cases (16%) and reduced in 8 cases (7%). Twenty-three patients (20%) were found inoperable. Intraoperative evaluation caused surgical modification by IOUS in 13 patients (11%), by surgical findings in 14 patients (12%) and by a combination of both in 23 patients (20%). CONCLUSION: IOUS is a precise diagnostic method for staging the operability of liver tumours. Unnecessary surgical procedures can be avoided. In total, IOUS altered the preoperative plan in one-third of our patients and is therefore recommended as a routine procedure in connection with major liver surgery.

[Contrast media in ultrasonography]. / Kontraststoffer til brug for UL-diagnostik.

Microbubbles of air or other gases are ideally suited as echo-enhancers because of the high difference in acoustic impedance of gas/fluid interfaces. The microbubbles are 1-7 microns in diameter and capable of surviving pulmonary passage to produce enhancement of especially the Doppler signal after intravenous injection. The main clinical role of ultrasound (US)-contrast is to enhance the Doppler signals (up to 20 dB) in inconclusive Doppler examinations. Experience with US-contrast agents comes mainly from use of the galactose based agent Levovist (Schering AG, Germany). The US-contrast agents have further properties: a) Air bubbles in the sound fields will reverberate and return sound with harmonic frequencies. This phenomenon can be used in "harmonic imaging". B) Short intense sound impulses will destroy the bubbles resulting in a mosaic of colours (stimulated acoustic emission). This phenomenon may be used in tumour diagnostics in the liver.

Percutaneous ethanol injection therapy in the treatment of thyroid and parathyroid diseases.

Relevant English language articles published from 1966 to 1995 regarding ethanol therapy in the treatment of thyroid and parathyroid diseases were identified through a MEDLINE search and manual searches of identified articles. The sclerosing properties of ethanol have been recognized for many years and have offered interventional possibilities in the management of various benign as well as malignant lesions. The mechanism of action of ethanol appears to be related to a direct coagulative necrosis and local partial or complete small vessel thrombosis. Ultrasound-guided percutaneous ethanol injection therapy (PEIT) is rapid and performed on an out-patient basis and has now gained wide acceptance due to the accumulating evidence of the efficacy and safety of this therapeutic tool. Yet, there is a lack of prospective, randomized clinical trials comparing PEIT with 131I therapy or surgery with regard to its effects, especially long-term ones and it should therefore still be considered an experimental procedure. In benign endocrine diseases, PEIT has shown promising results in the treatment of autonomous thyroid nodules, benign solitary cold solid as well as cystic thyroid nodules and parathyroid tumours. Its use in pretoxic and toxic thyroid nodules has been evaluated in several uncontrolled studies, all demonstrating a high success rate in spite of the large number of treatments needed. So far efficacy and cost-effectiveness seem inferior to 131I and surgery. Short-term results of PEIT in benign cystic thyroid nodules are convincing with a high cure rate, but no controlled studies with long-term results are available. Preliminary results suggest that PEIT could become an alternative to surgical excision or levothyroxine therapy in the symptomatic solid cold benign thyroid nodule. Ultrasound-guided PEIT of parathyroid tumours has proven to be a useful method in highly selected patients in whom surgery has been found non-attractive and medical treatment ineffective. However, no prospective randomized trials have been published comparing the results of PEIT in parathyroid tumours with conventional surgical and medical treatments. PEIT has never been tested against standard therapy, but seems inferior to 131I and surgery. Side-effects caused by ethanol injection are generally few and transient and are related to the injection into solid nodules rather than cysts. Ethanol injection into solid profund nodules may seriously jeopardize subsequent surgery because of perinodular fibrosis. As an experimental procedure, not yet evaluated sufficiently, it should be reserved for patients who cannot or will not undergo standard therapy. Caution in routine use is advisable.

Ultrasonically guided insertion of a peritoneo-gastric shunt in patients with malignant ascites.

PURPOSE: A new method for internal drainage of malignant ascites is presented in 5 patients with symptomatic malignant ascites. MATERIAL AND METHODS: US-guided percutaneous gastrostomy and paracentesis were performed using the Seldinger technique. A 2.5-mm Cope-loop catheter was inserted in the fluid-filled stomach. In the lower abdomen the proximal part of a Denver peritoneo-venous shunt was introduced after dilation up to 4.8 mm. The pump chamber was sutured to the skin. The distal part of the Denver shunt was cut a few cm from the pump chamber and connected to the gastrostomy catheter. When pumping, ascites is shunted to the stomach lumen. RESULTS: The insertion presented no complications, and all shunt systems initially functioned well. However, the shunts had to be removed within the first 2 weeks because of mechanical problems such as clotting, leakage, and peritoneal septum formation. No infections were reported. CONCLUSION: The peritoneo-gastric shunt may present a therapeutic alternative in selected patients, but the mechanical problems have first to be solved.

[Pulmonary arteriovenous malformations determined by color Doppler ultrasonography]. / Pulmonale arteriovenøse misdannelser påvist ved farve-Doppler-ultralydundersøgelse.

Pulmonary arteriovenous malformations are rare conditions, and are often misinterpreted on chest radiographs. We present a case in which peripherally localised pulmonary arteriovenous malformations were diagnosed by use of colour-Doppler ultrasonography.

Ultrasonically guided localization, tissue verification, and percutaneous treatment of parathyroid tumours.

The conventional treatment of patients with P-HPT is neck-surgery. A variety of imaging techniques has been used for localization of PT. These techniques are most conveniently divided into two categories: noninvasive imaging methods (US, CT, MR, thallium-technetium subtraction scintigraphy) and invasive localization procedures (imaging-guided biopsy/aspiration, parathyroid angiography, parathyroid venous sampling). Employing US it seems possible to localize about 2/3 of PT in patients with P-HPT before initial surgery. Most often, the PT appears as a rounded homogeneous mass with a lower echogenicity than that of the normal thyroid gland. However, the US characteristics may vary. False negative US findings are due to difficulties in detecting very small PT, and the inability to visualize PT localized in areas inaccessible to US. In patients with multinodular goitres the PT might be overlooked. False positive findings are mainly caused by misinterpretation of thyroid nodules as being enlarged parathyroid glands. In order to secure a reliable tissue diagnosis, US guided fine needle biopsies can be performed. Three different techniques were tested and found usable: aspiration biopsy either for PTH-measurement or cytological examination, and tissue biopsy for histological examination. When using aspiration biopsy for PTH-measurements, aspirates from both the suspected parathyroid tissue and from corresponding thyroid tissue are immunochemically analyzed for PTH concentration. A positive PTH-gradient-that is a higher PTH-concentration in the aspirates from the suspected PT-strongly indicates the presence of a PT. The usefulness of this technique may be hampered by accessibility and cost of the PTH-analysis. Cytological discrimination between parathyroid and thyroid cells might be difficult especially in specimens of low cellularity. Cytological examination of parathyroid cells is a method recently introduced in parallel with the possibilities of parathyroid visualization and percutaneous aspiration. Therefore, at present, reliable recognition of parathyroid cells can be expected only from cytologist with special interest and experience in parathyroid cytology. The histological appearance of parathyroid tissue is well known to most pathologists. The histological diagnosis of tissue samples obtained by US guided tissue biopsies is reliable. However, sufficient tissue for examination is obtained only in about half of the cases.(ABSTRACT TRUNCATED AT 400 WORDS)

Surgical treatment of primary hyperparathyroidism.

One hundred and two patients with primary hyperparathyroidism underwent a total of 108 bilateral neck explorations with attempted identification and biopsy of all four glands. Hypercalcaemia was surgically eliminated in 97 of 102 patients (95%). Of the remaining hypercalcaemic patients one was cured by percutaneous ethanol injection and one was reoperated and cured in another hospital. Three patients with persistent hypercalcaemia refused reoperation. Transitory hypocalcaemia with a median duration of 15 days was found in 36 patients, and permanent hypocalcaemia in two patients (1.9%). Permanent paralysis of the recurrent nerve occurred in three patients (2.9%). Twenty-one patients developed other postoperative complications from which they all recovered without sequelae. No postoperative deaths occurred. Our results show that surgical treatment of primary hyperparathyroidism--including bilateral neck exploration and attempted biopsies of all parathyroid glands--is safe with a high cure rate.

Percutaneous transhepatic external biliary drainage utilizing a pig tail balloon catheter.

A 2.3-mm soft pig tail balloon catheter was developed to be used for percutaneous transhepatic biliary drainage. A small balloon (OD 10 mm) secures an optimal internal fixation and side holes behind the balloon secure drainage of the cannulated bile duct peripheral to the balloon. Successful transhepatic biliary drainage with the pig tail balloon catheter was achieved in 11 of 12 patients for a period of 3 to 67 days (median 6 days). In one patient the catheter clogged after 55 days of drainage. No case of catheter dislodgement or other complications related to the external drainage was seen.

Technical note: ultrasound guided transvaginal drainage utilizing a 7 French pig tail balloon catheter.

Ultrasound guided transvaginal drainage of abscesses in the small pelvis is usually performed using needles or stiff pig tail catheters without internal fixation. To prevent dislodgement during the subsequent drainage and irrigation procedure, we have developed a new soft 7 F balloon catheter for continuous transvaginal drainage. The catheter is made of soft C-flex and contains two channels, one for drainage and one for inflating a small distal balloon (outer diameter, 10 mm).

Tertiary hyperparathyroidism treated by ultrasonically guided percutaneous fine-needle ethanol injection.

Advanced renal failure is often accompanied by secondary and tertiary hyperparathyroidism. In tertiary hyperparathyroidism it is necessary to reduce the gland mass. The present study describes the response to treatment with percutanous injection of ethanol of enlarged parathyroid nodules in 9 uremic patients. All had hypercalcemia, severely elevated serum levels of parathyroid hormone and ultrasonically detectable enlarged parathyroid glands. Three patients did not respond to the treatment. In the remaining 6 patients, serum values of total and ionized calcium were normalized and the serum values of parathyroid hormone were reduced at least 30% after 18 months. Seven of the patients experienced an improvement of symptoms. No complications were seen. We conclude that treatment with ethanol injection can be used as an alternative to conventional parathyroidectomy to improve parathyroid status in selected patients.