Prospective evaluation of Gadoxetate-enhanced magnetic resonance imaging and computed tomography for hepatocellular carcinoma detection and transplant eligibility assessment with explant histopathology correlation.

BACKGROUND: We aimed to prospectively compare the diagnostic performance of gadoxetic acid-enhanced MRI (EOB-MRI) and contrast-enhanced Computed Tomography (CECT) for hepatocellular carcinoma (HCC) detection and liver transplant (LT) eligibility assessment in cirrhotic patients with explant histopathology correlation. METHODS: In this prospective, single-institution ethics-approved study, 101 cirrhotic patients were enrolled consecutively from the pre-LT clinic with written informed consent. Patients underwent CECT and EOB-MRI alternately every 3 months until LT or study exclusion. Two blinded radiologists independently scored hepatic lesions on CECT and EOB-MRI utilizing the liver imaging reporting and data system (LI-RADS) version 2018. Liver explant histopathology was the reference standard. Pre-LT eligibility accuracies with EOB-MRI and CECT as per Milan criteria (MC) were assessed in reference to post-LT explant histopathology. Lesion-level and patient-level statistical analyses were performed. RESULTS: Sixty patients (49 men; age 33-72 years) underwent LT successfully. One hundred four non-treated HCC and 42 viable HCC in previously treated HCC were identified at explant histopathology. For LR-4/5 category lesions, EOB-MRI had a higher pooled sensitivity (86.7% versus 75.3%, p <  0.001) but lower specificity (84.6% versus 100%, p <  0.001) compared to CECT. EOB-MRI had a sensitivity twice that of CECT (65.9% versus 32.2%, p <  0.001) when all HCC identified at explant histopathology were included in the analysis instead of imaging visible lesions only. Disregarding the hepatobiliary phase resulted in a significant drop in EOB-MRI performance (86.7 to 72.8%, p <  0.001). EOB-MRI had significantly lower pooled sensitivity and specificity versus CECT in the LR5 category with lesion size < 2 cm (50% versus 79%, p = 0.002 and 88.9% versus 100%, p = 0.002). EOB-MRI had higher sensitivity (84.8% versus 75%, p <  0.037) compared to CECT for detecting < 2 cm viable HCC in treated lesions. Accuracies of LT eligibility assessment were comparable between EOB-MRI (90-91.7%, p = 0.156) and CECT (90-95%, p = 0.158). CONCLUSION: EOB-MRI had superior sensitivity for HCC detection; however, with lower specificity compared to CECT in LR4/5 category lesions while it was inferior to CECT in the LR5 category under 2 cm. The accuracy for LT eligibility assessment based on MC was not significantly different between EOB-MRI and CECT. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03342677 , Registered: November 17, 2017.

Can preoperative liver MRI with gadoxetic acid help reduce open-close laparotomies for curative intent pancreatic cancer surgery?

OBJECTIVES: To evaluate gadoxetic acid-enhanced liver MRI (EOB-MRI) versus contrast-enhanced computed tomography (CECT) for preoperative detection of liver metastasis (LM) and reduction of open-close laparotomies for pancreatic ductal adenocarcinoma (PDAC). METHODS: Sixty-six patients with PDAC had undergone preoperative EOB-MRI and CECT. LM detection by EOB-MRI and CECT and their impact on surgical planning, open-close laparotomies were compared by clinical and radiology reports and retrospective analysis of imaging by two blinded independent readers. Histopathology or imaging follow-up was the reference standard. Statistical analysis was performed at patient and lesion levels with two-sided McNemar tests. RESULTS: EOB-MRI showed higher sensitivity versus CECT (71.7% [62.1-80.0] vs. 34% [25.0-43.8]; p = 0.009), comparable specificity (98.6%, [96.9-99.5] vs. 100%, [99.1-100], and higher AUROC (85.1%, [80.4-89.9] vs. 66.9%, [60.9-73.1]) for LM detection. An incremental 7.6% of patients were excluded from surgery with a potential reduction of up to 13.6% in futile open-close laparotomies due to LM detected on EOB-MRI only. CONCLUSIONS: Preoperative EOB-MRI has superior diagnostic performance in detecting LM from PDAC. This better informs surgical eligibility with potential reduction of futile open-close laparotomies from attempted curative intent pancreatic cancer surgery.

Assessment of biliary anatomy in potential living liver donors: Added value of gadoxetic acid-enhanced T1 MR Cholangiography (MRC) including utilization of controlled aliasing in parallel imaging results in higher acceleration (CAIPIRINHA) technique in comparison to T2W-MRC.

OBJECTIVES: To assess the added value of gadoxetic-acid-enhanced T1-weighted magnetic resonance Cholangiography (T1W-MRC) including controlled aliasing in parallel imaging results in higher acceleration (CAIPIRINHA)-Volumetric Interpolated Breathhold (VIBE) technique compared to T2-weighted MR Cholangiography (T2W-MRC) in depicting biliary anatomy in potential living liver donors. METHODS: Eighty-five potential donors including 34 men with a mean age of 35.6 years (range, 18-55 years) and 51 women with a mean age of 36.7 years (range, 23-57 years), were enrolled in this ethics-approved retrospective study. Image quality for depiction of bile ducts was evaluated by two readers in consensus in 3 separate reading sessions: 1) T2W-MRC alone, 2) T1W-MRC alone (including CAIPI-VIBE and generalized autocalibrating partially parallel acquisitions (GRAPPA)-VIBE techniques, and 3) combined T1W/T2W-MRC. Accuracy of T2W-MRC, T1W-MRC, and combined T1W/T2W-MRC for the identification/classification of the biliary variants was calculated using intraoperative cholangiogram (IOC) as the reference standard. Image quality and reader diagnostic confidence provided by CAIPI-VIBE technique was compared with GRAPPA-VIBE technique. Datasets were compared using the Wilcoxon signed-rank test. RESULTS: Image quality for depiction of the bile ducts was significantly superior in the combined T1W/T2W-MRC group, when compared to each of T2W-MRC and T1W-MRC groups independently (P value = 0.001-0.034). The combination of CAIPI-VIBE and GRAPPA-VIBE was superior compared to each of the sequences individually. The accuracy of T2W-MRC and T1W-MRC was 93% and 91%, respectively. T1W-MRC depicted four biliary variants better than T2W-MRC. Two variants not well seen in T2W-MRC were clearly shown on T1W-MRC. CONCLUSION: Gadoxetic-acid-enhanced T1W-MRC and conventional T2W-MRC techniques are complementary for depiction of biliary variants in potential liver donors and the combination of the two improves the results. The combination of CAIPI-VIBE and GRAPPA-VIBE techniques appear to be complementary for optimal diagnostic yield of T1W-MRC.

Intra-sheath versus extra-sheath ultrasound guided corticosteroid injection for trigger finger: a triple blinded randomized clinical trial.

OBJECTIVE: The aim of this study is to compare clinical results of ultrasound-guided corticosteroid injection, intra-sheath versus extra-sheath of the finger flexor tendon. METHODS: A total of 166 patients with trigger finger were evaluated in a triple blind randomized clinical trial study. All the patients were injected with 1ml of 40mg/ml methyl prednisolone acetate, under the guidance of ultrasound. Half the patients were injected extra sheath, while the other half were injected intra sheath at the level of first annular pulley. RESULTS: The two groups were comparable in baseline characteristics (age, gender, dominant hand, involved hand and finger, and the symptoms duration). No significant difference was observed in the two groups with regards to Quinnell grading. In the final visit, 94% of patients from each group were symptom free. CONCLUSION: Results of corticosteroid injection intra-sheath or extra-sheath of the finger flexor tendon under ultrasound guidance in patients with trigger finger are comparably alike. Extra-sheath injection at the level of A1 pulley is as effective as an Intra-sheath administration.

A Randomised Clinical Trial to Compare Coaxial and Noncoaxial Techniques in Percutaneous Core Needle Biopsy of Renal Parenchyma.

PURPOSE: To compare the coaxial and noncoaxial techniques of renal parenchymal core needle biopsy. MATERIALS AND METHODS: This is an institutional review board-approved randomised controlled trial comparing 83 patients (male, n = 49) who underwent renal parenchymal core biopsy with coaxial method and 83 patients (male, n = 40) with noncoaxial method. The rate of complications, the number of glomerular profiles, and the procedural time were evaluated in a comparison of the two methods. Correlation between the presence of renal parenchymal disease and the rate of complication was also evaluated. RESULTS: The procedural time was significantly shorter in the coaxial technique (coaxial group, 5 ± 1 min; noncoaxial group, 14 ± 2 min; p < 0.001). The rates of complications for the coaxial method was significantly lower than the noncoaxial method (coaxial group, 10.8 %; noncoaxial group, 24.1 %; p = 0.025). There was no significant correlation between gender and the rate of complication. The number of glomerular profiles was significantly higher in patents who underwent renal biopsy with the coaxial method (coaxial group, 18.2 ± 9.1; noncoaxial group, 8.6 ± 5.5; p < 0.001). In the whole study population, the rate of complications was significantly higher in patients with a pathologic renal parenchyma compared to those with a normal parenchyma (19/71 vs. 10/95; p = 0.006). CONCLUSIONS: Renal parenchymal biopsy using a coaxial needle is a faster and safer method with a lower rate of complications.

Comparison of Indirect MR Arthrography With Conventional MRI in the Diagnosis of Knee Pathologies in Patients With Knee Pain.

BACKGROUND: Knee pain is a common problem in the general population. In order to determine the extent of the injury and the appropriate treatment, MRI provides the most accurate imaging method. This may be done through conventional MRI techniques or by injecting a contrast material (MR arthrography). OBJECTIVES: The purpose of this study was to compare the diagnostic value of these two methods. PATIENTS AND METHODS: The study involved the diagnostic evaluation on 60 patients with knee pain who received treatment over the course of a one-year period. Referred patients were randomly divided into two groups: indirect MR arthrography was performed on one group, and conventional MRI was performed on the other group. Both groups then underwent arthroscopy. The results from both groups were compared with the arthroscopic findings. RESULTS: In all of the pathologies studied, the sensitivity, specificity, and the positive and negative predictive values were evaluated. A high rate of accuracy was found between MR arthrography and arthroscopy (P < 0.05) for all knee injuries, however a similar rate of accuracy between conventional MRI and arthroscopy was only seen in patients with damage to the posterior cruciate ligament (PCL), the tibio-femoral articular cartilage, and patella chondromalacia (P < 0.05). The highest rate of accuracy was seen in cases where indirect MR arthrography was used for the diagnosis of anterior cruciate ligament (ACL) damage (K = 1). CONCLUSIONS: Our results have shown that indirect MR arthrography had greater diagnostic accuracy in regards to the sensitivity, specificity, and positive and negative predictive values than conventional MRI in knee pathologies.

Transperineal Prostate Core Needle Biopsy: A Comparison of Coaxial Versus Noncoaxial Method in a Randomised Trial.

PURPOSE: To compare the procedural time and complication rate of coaxial technique with those of noncoaxial technique in transperineal prostate biopsy. MATERIALS AND METHODS: Transperineal prostate biopsy with coaxial (first group, n = 120) and noncoaxial (second group, n = 120) methods was performed randomly in 240 patients. The procedural time was recorded. The level of pain experienced during the procedure was assessed on a visual analogue scale (VAS), and the rate of complications was evaluated in comparison of the two methods. RESULTS: The procedural time was significantly shorter in the first group (p < 0.001). In the first group, pain occurred less frequently (p = 0.002), with a significantly lower VAS score being experienced (p < 0.002). No patient had post procedural fever. Haematuria (p = 0.029) and haemorrhage from the site of biopsy (p < 0.001) were seen less frequently in the first group. There was no significant difference in the rate of urethral haemorrhage between the two groups (p = 0.059). Urinary retention occurred less commonly in the first group (p = 0.029). No significant difference was seen in the rate of dysuria between the two groups (p = 0.078). CONCLUSIONS: Transperineal prostate biopsy using a coaxial needle is a faster and less painful method with a lower rate of complications compared with conventional noncoaxial technique.

Application of bland-altman method in comparing transrectal and transabdominal ultrasonography for estimating prostate volume.

BACKGROUND: Estimating prostate volume using less invasive transabdominal ultrasonography (TAUS) instead of transrectal ultrasonography (TRUS) is of interest in terms of identifying their agreement level. Previous reports on this subject, applied general correlation coefficient as the level of agreement. This study uses Bland-Altman method to quantify TAUS and TRUS agreement on estimating prostate volume. METHODS: Total prostate gland volume of 40 patients with signs and symptoms of benign prostatic hyperplasia were measured using TAUS and TRUS. The study was carried out at the Urology Research Center, Razi Hospital, Guilan University of Medical Sciences (Rasht, Iran) from March to October 2010. Both methods were performed in one session by the same experienced radiologist. Data were analyzed using Pearson correlation coefficient and Bland-Altman method. RESULTS: Total prostate volume estimated by TAUS and TRUS were 50.30±23 and 50.73±24.6 mL, respectively. The limits of agreement for the total prostate volume were -6.86/9.84 that was larger than predefined clinical acceptable margin of 5 mL. CONCLUSION: There is a lack of agreement between TAUS and TRUS for estimating the total prostate volume. It is not recommended to apply TAUS instead of TRUS for estimating prostate volume.

Real-time scrotal ultrasound of patients with varicoceles: correlation with impaired semen analysis.

OBJECTIVES: To evaluate the potential relationship between scrotal ultrasound findings and abnormal semen analysis. METHODS: Eighty-seven patients with varicoceles underwent semen analysis and scrotal sonography. On ultrasound, estimated testes volume and the largest pampiniform vein diameters on the affected side at rest and with Valsalva manoeuvre in both the supine and upright positions were examined. In addition, the differences between the largest venous diameters at rest and during the Valsalva manoeuvre in each position (supine and upright) and also the differences between the largest venous diameter in the supine position and the upright position in each condition (at rest and during the Valsalva manoeuvre) were calculated. The relationship between various ultrasound parameters and impaired semen analysis was evaluated using receiver operating characteristic curves. RESULTS: Seventy-one patients had spermatogenesis impairment, and the remaining 16 had normal semen analysis. The difference in the mean spermatic vein diameter at rest between the supine and upright positions (cut-off point, 0.25 mm) had the highest diagnostic accuracy in differentiating the patients with abnormal sperm analysis from those with normal spermatogenesis with an area under the curve of 0.86. CONCLUSIONS: Real-time scrotal ultrasound can be helpful in predicting abnormal sperm analysis in patients with varicoceles. KEY POINTS: Scrotal ultrasound is a non-invasive method to evaluate spermatic veins in varicoceles. Ultrasound can evaluate venous dimension change at rest after upright position (ΔD(R) ). ΔD( R) > 2.5 mm distinguishes patients with abnormal semen analysis. ΔD( R) has the most accuracy in predicting abnormal spermatogenesis. Ultrasound findings improve differentiation between patients with abnormal and normal spermatogeneses.

Doppler surrogate endoscopy for screening esophageal varices in patients with cirrhosis.

BACKGROUND: Portal hypertension is a common consequence of hepatic cirrhosis, which causes esophageal varices. Bleeding from varices has a high mortality rate. The present gold standard for diagnosing varices is endoscopy. Considering endoscopy side effects and patients' low acceptance, there have been always efforts for finding alternative diagnostic methods including Doppler ultrasonography (US). OBJECTIVES: The aim of the present study was to evaluate changes of Doppler indices in cirrhotic patients with and without esophageal varices. PATIENTS AND METHODS: Sixty six patients with known cirrhosis entered this cross-sectional study. Gastroscopy was performed for patients, and the first questionnaire was filled based on the Japanese Portal Hypertension Society guidelines. Then patients were referred for Doppler US of splenoportal system, and information was documented in the second questionnaire. RESULTS: Forty-four patients were male and 22 female. Forty six patients had esophageal varices, and 20 did not. There were no significant associations between splenoportal indices found by Doppler US, and presence of esophageal varices in patients. However, we found a negative association between platelet ratio to spleen diameter, and to splenic vein diameter. CONCLUSIONS: Neither of studied variables was perfect to differentiate cirrhotic patients with and without EVs. Endoscopy is still the gold standard diagnostic method for diagnosing esophageal varices in patients with cirrhosis. It seems that some of the splenoportal Doppler indices are promising, but more research and evaluation is necessary.

Knee sonography as a diagnostic test for medial meniscal tears in young patients.

PURPOSE: To prospectively evaluate whether age of patient affects diagnostic accuracy of sonography and magnetic resonance imaging (MRI) in the diagnosis of medial meniscal tears. METHODS: We prospectively evaluated 74 consecutive patients (54 males and 20 females), in two different groups [group A (37 patients ≤ 30 years; mean age: 23.5 ± 5 years) and group B (37 patients > 30 years; mean age: 43.5 ± 9.35 years)] with clinical suspicion of medial meniscal tear. After inclusion, patients underwent ultrasonography and then MRI for signs of tearing. The ultrasonographic and MRI findings were compared with arthroscopic findings, which served as a gold standard for accurate detection of meniscal tearing. RESULTS: The sensitivity, specificity, positive and negative predictive values and accuracy of ultrasonography in detecting medial meniscal tears in group A were 100, 88.9, 96.5, 100, 97.3% and in group B were 83.3, 71.4, 92.6, 50, 81.1%, respectively. The sensitivity, specificity, positive and negative predictive values and accuracy of MRI in group A were 100, 88.9, 96.5, 100, 97.3% and in group B were 96.7, 85.7, 96.7, 85.7, 94.6%, respectively. CONCLUSIONS: Given the fact that the sensitivity and specificity of the results of knee sonography matched that of MRI in patients who were 30 years old or less, we suggest ultrasonography as an effective initial investigation for tears of medial meniscus in this group of patients. Patients with negative ultrasonographic findings will need no further investigation. LEVEL OF EVIDENCE: Diagnostic studies-investigating a diagnostic test, Level II.

The discovery of a Persian family with a form of Birt-Hogg-Dubé syndrome lacking the typical cutaneous stigmata of the syndrome.

PURPOSE: This study was performed in 24 members of a family with spontaneous pneumothorax to test clinical suspicion of Birt-Hogg-Dubé syndrome (BHDS). METHODS: Computed tomography scan was performed for confirmation of pneumothorax, while genetic tests were done using real-time quantitative polymerase chain reaction. RESULTS: Genetic studies showed a deletion of exon 1 in the FLCN gene in the index case as well as nine other individuals, including two with clinical phenotypes of pneumothorax and seven who are symptom-free to date. CONCLUSIONS: Proper imaging and taking accurate family history could be the keys to test clinical suspicion in some syndromes, including BHDS.

Ultrasonic measurement of common carotid intima-media thickness in type 2 diabetic and non-diabetic patients.

BACKGROUND: Diabetes mellitus is a widespread disease. Its vascular complications can be characterized by arteriosclerosis formation in carotid arteries. Due to its delayed diagnosis resulting in more complications in Iran, it seems that screening diabetic patients is mandatory. OBJECTIVES: The aim of this study was to compare the intima-media thickness (IMT) of carotid artery in diabetic and non-diabetic patients. PATIENTS AND METHODS: This is a cross-sectional study, which included 80 participants (40 diabetics and 40 non-diabetics). By using ultrasound, bilateral IMTs of the distal carotid were measured and the data were analyzed using ANOVA and multivariate regression tests in SPSS 14. RESULTS: The mean IMT was 0.97 in diabetic patients and 0.63 in non-diabetics (P < 0.001). Age and gender had significant positive effects on the increase of IMT (P < 0.05 and P < 0.005, respectively for age and gender). Past medical history of coronary heart disease (CHD) and cerebrovascular accident (CVA) in diabetes is associated significantly with an increase in IMT (P =0.019 and 0.027 respectively). Other confounding variables such as smoking, history of hypertension (HTN) and hyperlipoproteinemia (HLP) in diabetic patients showed no significant relationship with the increase of IMT. CONCLUSIONS: Although measuring the IMT of the carotid artery by sonography is a useful tool for screening diabetic patients, more studies are needed for determining how to use these measurements in promoting the patients outcomes.

Gastrointestinal manifestations of patients with chronic granulomatous disease.

Chronic Granulomatous Disease (CGD) represents a group of inherited disorders of phagocytic system, manifesting recurrent infections at different sites. The present study was accomplished in order to determine the gastrointestinal manifestations of CGD patients. Fifty-seven patients (38 males and 19 females) with CGD, who had been referred to three immunodeficiency referral centers in Iran, were studied during a 24-year period (1980-2004). The median age at the time of study was 14.5 years old (1-56 years). The median onset age of symptoms was 5 months (1 month- 13.75 years), and that of diagnostic age was 5 years (2 months- 54.1 years), with a diagnostic delay of 33 months, on average. Seven patients were presented with acute diarrhea, 3 with oral candidiasis, and 2 with liver abscesses as the first chief complaints. Twenty-four cases (42.1%) had been complicated by gastrointestinal manifestations during their course of the disease. Of those, 12 cases (21.1%) had diarrhea, 7 (12.3%) oral candidiasis, 5 (8.8%) hepatitis, 4 (7.0%) hepatic abscess, and 2 cases (3.5%) gastric outlet obstruction. Also, failure to thrive was detected in 6 patients (10.5%). Four patients died (7%). CGD should be excluded in any patient with gastrointestinal manifestations especially chronic diarrhea, hepatic abscess, and gastric outlet obstruction.