Contrast-enhanced ultrasound (CE-US), contrast CT scan and gadolinium dynamic MRI are recommended for the characterisation of liver nodules detected during surveillance of patients with cirrhosis ...with US.
To assess the sensitivity, specificity, diagnostic accuracy and economic impact of all possible sequential combinations of contrast imaging techniques in patients with cirrhosis with 1-2 cm liver nodules undergoing US surveillance.
64 patients with 67 de novo liver nodules (55 with a size of 1-2 cm) were consecutively examined by CE-US, CT, MRI, and a fine-needle biopsy (FNB) as diagnostic standard. Undiagnosed nodules were re-biopsied; non-malignant nodules underwent enhanced imaging follow-up. The typical radiological feature of hepatocellular carcinoma (HCC) was arterial phase hypervascularisation followed by portal/venous phase washout.
HCC was diagnosed in 44 (66%) nodules (2, <1 cm; 34, 1-2 cm; 8, >2 cm). The sensitivity of CE-US, CT and MRI for 1-2 cm HCC was 26, 44 and 44%, with 100% specificity, the typical vascular pattern of HCC being identified in 22 (65%) by a single technique versus 12 (35%) by at least two techniques carried out at the same time point (p=0.028). Compared with the cheapest dual examination (CE-US+CT), the cheapest single technique of stepwise imaging diagnosis of HCC was equally expensive (euro 26 440 vs euro 28 667), but led to a 23% reduction of FNB procedures (p=0.031).
In patients with cirrhosis with a 1-2 cm nodule detected during surveillance, a single imaging technique showing a typical contrast pattern confidently permits the diagnosis of HCC, thereby reducing the need for FNB examinations.
This study explored the potential of hemodynamic disturbances and geometric features to predict long-term carotid restenosis after carotid endarterectomy (CEA). Thirteen CEA for carotid diameter ...stenosis > 70% were performed with patch graft (PG) angioplasty in nine cases, and primary closure (PC) in four cases. MRI acquisitions within one month after CEA were used for hemodynamic and geometric characterization. Personalized computational hemodynamic simulations quantified the exposure to low and oscillatory wall shear stress (WSS). Geometry was characterized in terms of flare (the expansion at the bulb) and tortuosity. At 60 months after CEA, Doppler ultrasound (DUS) was applied for restenosis detection and intima-media thickness determination. Larger flares were associated to larger exposure to low WSS (Pearson
R
2
values up to 0.38,
P
< 0.05). The two cases characterized by the highest flare and the largest low WSS exposure developed restenosis > 50% at 60 months. Linear regressions revealed associations of DUS observations of thickening with flare variables (up to
R
2
= 0.84,
P
< 0.001), and the exposure to low (but not oscillatory) WSS (
R
2
= 0.58,
P
< 0.05). Our findings suggest that arteriotomy repair should avoid a large widening of the carotid bulb, which is linked to restenosis
via
the generation of flow disturbances. Hemodynamics and geometry-based analyses hold potential for (1) preoperative planning, guiding the PG vs. PC clinical decision, and (2) stratifying long-term restenosis risk after CEA.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Management of hepatocellular carcinoma (HCC) is framed within standardized protocols released by Scientific Societies, whose applicability and efficacy in field practice need refining.
Aim
...We evaluated the applicability and effectiveness of guidelines for the treatment of HCC of the American Association for the Study of the Liver (AASLD).
Methods
370 consecutive cirrhotic patients with de novo HCC in different stages, 253 BCLC A, 66 BCLC B, 51 BCLC C received treatment through a multidisciplinary team (MDT) decision and were followed until death or end of follow‐up.
Results
Treatment was adherent to AASLD recommendations in 205 (81%) BCLC A patients, 36 (54%) BCLC B, and 27 (53%) BCLC C. Radiological complete response was achieved in 165 (45%) patients after the first‐line treatment, in 22 (19%) after a second‐line and in 9 (23%) after a third‐line treatment. Adherence to AASLD recommendation allowed a lower yearly mean mortality rate in BCLC A patients compared with other treatment (5.0% vs 10.4% P = .004), whereas upward treatment stage migration compared with the standard of care was associated with reduced yearly mortality in BCLC B (8.6% vs 20.7%, P = .029) and BCLC C (42.6% vs 59.0%, P = .04) patients.
Conclusions
HCC multimodality treatment including other than first‐line therapy is common in clinical practice and impact on the achievement of complete response. Personalized treatment was able to provide survival benefits to patients whose profile is not accounted for by international recommendations, which need to be amended.
See Editorial on Page 1550
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
Objective Evaluating the long-term outcomes of vocal fold structural fat grafting. Study Design Case series with chart review. Setting University hospital. Subjects and Methods Seventy-nine dysphonic ...patients (16-82 years; 55 with unilateral laryngeal paralysis and 24 with vocal fold scarring) underwent vocal fold fat injection. Fat was harvested by low-pressure liposuction and then processed by centrifugation. Refined fat aliquots were placed in the vocal fold and paraglottic space in multiple tunnels to enhance graft neovascularization. All patients were followed for 12 months, 15 for 3 years, and 5 for 10 years with videolaryngostroboscopy, maximal phonation time (MPT) measurement, Voice Handicap Index (VHI) questionnaire, and GRBAS (grade, roughness, breathiness, asthenia, strain) perceptual evaluation. Laryngeal computed tomography (CT) and/or magnetic resonance imaging (MRI) studies were performed in 16 patients 3 to 28 months postoperatively; MRI was repeated in 5 cases 12 to 18 months after the first radiological study. Results The voice quality of all patients improved after surgery, and long-term stability was confirmed by MPT, GRBAS, and VHI ( P ranging between .004 and <.001). The results achieved 1 year postoperatively remained stable at 3 and 10 years. Videolaryn-gostroboscopy showed improved glottic closure in all patients despite a limited amount of fat resorption. CT and MRI demonstrated survival of the fat grafts in all of the 16 examined cases. Serial MRI scans showed no change in graft size over time. Conclusions The reported clinical and radiological data demonstrate that fat is an effective filler for permanent vocal fold augmentation if the refined micro-aliquots are placed in multiple tunnels.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
AbstractIntroduction and aimThe American Association for the Study of the Liver (AASLD) recommends contrast computerized tomography (CT-scan) and magnetic resonance (MRI) to diagnose hepatocellular ...carcinoma (HCC) arising in cirrhotic patients under semiannual surveillance with abdominal ultrasound (US). A US guided fine needle biopsy (FNB) serves the same purpose in radiologically undiagnosed tumors and incidentally detected nodules in cirrhotics outside surveillance. In this population, we evaluated the performance of radiological diagnosis of HCC according to 2010 AASLD recommendations. Materials and methodsAll cirrhotic patients with a liver nodule incidentally detected by US were prospectively investigated with a sequential application of CT-scan/MRI examination and a FNB. ResultsBetween 2011 and 2015, 94 patients (mean age 67 years) had a liver nodule (total 120) detected by US in the context of histologically confirmed cirrhosis. Mean nodules diameter was 40 (10–160) mm, 87 (73%) <5 cm. At histology, 84 (70%) nodules were HCC, 8 (7%) intrahepatic cholangiocarcinoma, 6 (5%) metastases, 2 (2%) neuroendocrine tumors and 20 (16%) benign lesions. Hyperenhancement in arterial phase followed by wash-out in venous phases on at least one radiological technique was demonstrated in 62 nodules (61 HCC, 1 high grade dysplastic nodule), with a specificity of 97% (IC95%: 85–100%), sensitivity 73% (IC95%: 62–81%) and diagnostic accuracy 80%, being 64% for ≥5 cm HCC. Sensitivity of AFP >200 ng/mL was 12% (IC95%: 6–23%). ConclusionA single contrast imaging technique showing a typical contrast pattern confidently identifies HCC also in cirrhotic patients with an incidental liver nodule, thereby reducing the need for FNB examinations.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Assessment of the activity of perianal fistulas may be of clinical relevance in patients with Crohn's disease. Fistula activity is currently evaluated by means of magnetic resonance imaging; anal ...ultrasound can also be used, but its diagnostic performance in this setting remains to be defined. Our aims were to evaluate the agreement between clinical examination, magnetic resonance imaging, and anal ultrasound in assessing perianal fistula activity, and to apply computerized analysis to improve the assessment of ultrasound images.
Thirty-one consecutive patients with Crohn's perianal fistulas underwent clinical examination, and magnetic resonance and anal ultrasound imaging. Active fistulas were defined as the presence of active drainage or signs of local inflammation on clinical examination, and the definition was confirmed by surgical examination. Activity was assessed on the basis of T2 hyperintensity on magnetic resonance imaging and the degree of hypoechogenicity on anal ultrasound; the anal ultrasound images were also analyzed using dedicated computer image-analysis software.
Twenty-five patients had an active fistula at clinical examination. The agreement between clinical examination and magnetic resonance imaging was good (k-value = 0.739), whereas that with anal ultrasound was only fair (k-value = 0.266-0.294); computer-assisted analysis of the anal ultrasound images improved the agreement from fair to good (k-value = 0.608-0.670).
Anal ultrasound can be used to assess fistula track activity in patients with Crohn's disease. The diagnostic performance of the technique can be improved to values comparable with those of magnetic resonance imaging by using a computer-assisted evaluation of the anal ultrasound images.
Background & Aims
The diagnostic accuracy of Liver Imaging Reporting and Data System (LI‐RADS) v.2018 and European Association for the Study of the Liver (EASL) criteria for the diagnosis of HCC have ...been widely evaluated, but their reliability should be investigated. We aimed to assess and compare the reliability of LI‐RADS v.2018 and EASL criteria for the diagnosis of HCC using MRI with extracellular contrast agents (ECAs) and gadoxetic acid (GA) and determine the effect of ancillary features on LI‐RADS reliability.
Approach & Results
Ten readers reviewed MRI studies of 92 focal liver lesions measuring <3 cm acquired with ECAs and GA <1 month apart from two prospective trials, assessing EASL criteria, LI‐RADS major and ancillary features, and LI‐RADS categorization with and without including ancillary features. Inter‐reader agreement for definite HCC diagnosis was substantial and similar for the two contrasts for both EASL and LI‐RADS criteria. For ECA‐MRI and GA‐MRI, respectively, inter‐reader agreement was k = 0.72 (95% CI, 0.63–0.81) and k = 0.72 (95% CI, 0.63–0.80); for nonrim hyperenhancement, k = 0.63 (95% CI, 0.54–0.72) and k = 0.57 (95% CI, 0.48–0.66); and for nonperipheral washout, k = 0.49 (95% CI, 0.40–0.59) and k = 0.48 (95% CI, 0.37–0.58) for enhancing capsule. The inter‐reader agreement for LI‐RADS after applying ancillary features remained in the same range of agreement.
Conclusions
Agreement for definite HCC was substantial and similar for both scoring systems and the two contrast agents in small focal liver lesions. Agreement for LI‐RADS categorization was lower for both contrast agents, and including LI‐RADS ancillary features did not improve agreement.
•The reliability of extracellular contrast and gadolinium in small liver lesions using LI‐RADS and EASL criteria have been investigated.
•The agreement for definite HCC was substantial and similar for both contrast agents and scoring systems, but the agreement for LI‐RADS categorization was lower.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Small synovial cysts are a common manifestation of juvenile idiopathic arthritis; large brachial cysts, however, are a rare sign of the disease and they must be differentiated from other soft tissue ...swelling which are not related to articular involvement. We describe the case of three children with juvenile idiopathic arthritis who came to our attention with large synovial cysts. Ultrasonographic examination and MRI were performed in all cases, showing the real nature of the swelling and the connection to the joint. In all cases, swelling reduced and then disappeared with control of disease activity; in two cases, they reappeared in coincidence with a severe relapse of juvenile idiopathic arthritis.
Brachial swellings represent a diagnostic challenge because they can be the clinical expression of a variety of diseases. In children with juvenile idiopathic arthritis who present with a sudden swelling of the upper arm, synovial cysts must be considered in the diagnostic workout, because they are a possible rare manifestation of juvenile idiopathic arthritis.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
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