Prognostic value of subclassification using MRI in the t4 classification nasopharyngeal carcinoma intensity-modulated radiotherapy treatment

PURPOSE

To subclassify patients with the T4 classification nasopharyngeal carcinoma (NPC), according to the seventh edition of the American Joint Committee on Cancer staging system, using magnetic resonance imaging (MRI), and to evaluate the prognostic value of subclassification after intensity-modulated radiotherapy (IMRT).

METHODS AND MATERIALS

A total of 140 patients who underwent MRI and were subsequently histologically diagnosed with nondisseminated classification T4 NPC received IMRT as their primary treatment and were included in this retrospective study. T4 patients were subclassified into two grades: T4a was defined as a primary nasopharyngeal tumor with involvement of the masticator space only; and T4b was defined as involvement of the intracranial region, cranial nerves, and/or orbit.

RESULTS

The 5-year overall survival (OS) rate and distant metastasis-free survival (DMFS) rate for T4a patients (82.5% and 87.0%, respectively), were significantly higher than for T4b patients (62.6% and 66.8%; p = 0.033 and p = 0.036, respectively). The T4a/b subclassification was an independent prognostic factor for OS (hazard ratio = 2.331, p = 0.032) and DMFS (hazard ratio = 2.602, p = 0.034), and had no significant effect on local relapse-free survival.

CONCLUSIONS

Subclassification of T4 patients, as T4a or T4b, using MRI according to the site of invasion, has prognostic value for the outcomes of IMRT treatment in NPC.

Contrast-enhanced ultrasound features of hepatocellular carcinoma of different sizes

AIM: To analyze the contrast-enhanced ultrasound (CEUS) features of hepatocellular carcinoma (HCC) of different sizes.

METHODS: A total of 75 consecutive patients with 90 HCC lesions were enrolled. HCC was examined by CEUS and confirmed by surgery and pathology. These patients were divided into two groups according to the maximum diameter of the lesion: small HCC (SHCC) group (diameter ≤3 cm) and large HCC (LHCC) group (>3 cm). The CEUS characteristics of HCC of different sizes were analyzed retrospectively.

RESULTS: Among 90 lesions, 39 were small HCC (SHCC) and 51 were large HCC (LHCC). During the arterial phase, all the 39 lesions in the SHCC group exhibited hyperenhancement, of which 37 (94.9%) were homogeneously and 2 (5.1%) were inhomogeneously enhanced. Comparatively, all the 51 lesions in the LHCC group exhibited hyperenhancement, of them 27 (52.9%) appeared as homogeneous enhancement, 21 (41.2%) as inhomogeneous enhancement and 6 (6%) as atypical patterns. The enhancement patterns had significant difference during the arterial phase between the two groups (P < 0.05). During the portal phase, 10 (25.6%) lesions were isoechoic and 29 (74.4%) were hypoechoic in the SHCC group, while 7 (13.7%) lesions were hyperechoic, 2 were isoechoic (3.9%), and 42 (82.4%) were hypoechoic in the LHCC group. A significant difference was also noted in enhancement patterns during the portal phase between the two groups (P < 0.05). During the late phase, hypoenhancement was visualized in all the SHCC lesions, while in the LHCC group, hypoenhancement was visualized in 50 (98%) lesions and isoenhancement in 1 (2%) lesion. No significant difference was observed in enhancement patterns during the late phase between the two groups.

CONCLUSION: Our study shows that the enhancement manifestations of HCC are related to lesion size. During the arterial phase, most SHCC lesions show homogeneous enhancement, while inhomogeneous enhancement patterns appear mostly in LHCC lesions. During the portal and late phases, SHCC lesions may be washed out earlier than LHCC ones.

The precarious state of the liver after a Fontan operation: summary of a multidisciplinary symposium

As the cohort of survivors with the single-ventricle type of congenital heart disease grows, it becomes increasingly evident that the state of chronically elevated venous pressure and decreased cardiac output inherent in the Fontan circulation provides the substrate for a progressive decline in functional status. One organ at great risk is the liver. Wedged between two capillary beds, with the pulmonary venous bed downstream, which typically has no pulsatile energy added in the absence of a functional right ventricle, and the splanchnic bed upstream, which may have compromised inflow due to inherent cardiac output restriction characteristic of the Fontan circulation, the liver exists in a precarious state. This review summarizes a consensus view achieved at a multidisciplinary symposium held at The Children's Hospital of Philadelphia in June 2011. The discussion includes current knowledge concerning the hemodynamic foundations of liver problems, the diagnostic tools available, the unique histopathology of the liver after the Fontan operation, and proposed mechanisms for hepatic fibrosis at the cellular level. At the completion of the symposium, a consensus recommendation was made by the authors' group to pursue a new prospective protocol for clinical evaluation of the liver for all patients in our practice 10 years after the Fontan operation.

Mirizzi Syndrome: Experience in Diagnosis and Treatment of 25 Cases

The objective of this study is to summarize the experience in diagnosis and treatment of Mirizzi syndrome (MS) and reduce the incidence of operative complications. Twenty-five cases of Mirizzi syndrome from January 2005 to January 2010 were retrospectively analyzed. There were 11 male patients and 14 female patients, ranging in ages from 26 to 80 years with a median age of 51.3. Preoperative radiological diagnosis was achieved in 10 patients: ultrasonography (n = 5) and magnetic resonance cholangiopancreatography (n = 10). The others were diagnosed intra-operatively. Fifteen patients had Type I MS. Two were treated with laparoscopic cholecystectomy successfully. The laparoscopic procedure had to be converted to open procedure in one patient. Seven patients had open complete cholecystectomy, three had subtotal cholecystectomy, and two had removal of stones from the gall bladder and choledochostomy after cholecystotomy was performed, with secondary cholecystectomy 3 months later. Six patients had Type II MS. Five underwent cholecystectomy, common bile duct (CBD) repair, and T-tube insertion. One was managed with transection of CBD and Roux-en-Y hepaticojejunostomy. Two patients with Type III MS underwent cholecystectomy, CBD repair, and T-tube insertion. Cholecystectomy and Roux-en-Y hepaticojejunostomy was performed in the two patients with Type IV MS. All the patients recovered from the operation. The follow-up period ranged from 5 years to 5 months. One patient developed obstructive jaundice more than 2 years after the operation, and recovered after the secondary operation. The follow-up of others were uneventful. Preoperative diagnosis of MS is very difficult. Magnetic resonance cholangiopancreatography is very helpful in preoperative diagnosis, and a high index of clinical suspicion is required to make a preoperative or intra-operative diagnosis, which can lead to correct operative strategy to manage Mirizzi syndrome.

A multimodal approach to the management of neuroendocrine tumour liver metastases

Neuroendocrine tumours (NETs) are often indolent malignancies that commonly present with metastatic disease in the liver. Surgical, locoregional, and systemic treatment modalities are reviewed. A multidisciplinary approach to patient care is suggested to ensure all therapeutic options explored.

Congenital bronchial atresia: diagnosis and treatment

This study aimed to retrospectively summarize the clinical signs, diagnosis, and treatment of congenital bronchial atresia (CBA) in 12 patients. Chest radiographs and computed tomographic (CT) images of 12 patients with CBA treated in the Chinese People's Liberation Army General Hospital were reviewed. Analysis of chest radiographs revealed ten patients had hilar mass-like shadows and two had pneumonia-like shadows; most patients (n = 8) showed hyperlucency of the peripheral lung fields. CT revealed a mucocele in all the patients (n = 12); the mucoceles were round in four patients and club-like in eight. In 80% of the cases (n = 10), associated anomalies, including occlusions of the bronchus central to the mucocele, emphysematous changes of the peripheral lung fields, bronchogenic cyst, and anomalous branching of the bronchial tree and vascular structure were observed. CBA was detected in the right lobe in eight patients and the left lobe in the remaining four. No surgical intervention was performed in 5 CBA patients and the remaining 7 patients underwent surgery, including lobectomy in 5 patients and local resection in 2 patients. Among these 7 patients, 3 had a preoperative diagnosis of malignant disease, and the remaining 4 had severe clinical symptoms that could not be effectively treated by medicines. All patients were followed up, and none experienced obvious discomfort. CBA is a relatively rare and benign malformation disease. Chest CT is the procedure of choice for diagnosis. The presence of a bronchocele and surrounding emphysematous changes are typical radiologic findings in CBA. Surgery should be reserved only for patients with serious complications secondary to the atretic bronchus.

Eu(II)-containing cryptates as contrast agents for ultra-high field strength magnetic resonance imaging

The relaxivity (contrast-enhancing ability) of Eu(II)-containing cryptates was found to be better than a clinically approved Gd(III)-based agent at 7 T. These cryptates are among a few examples of paramagnetic substances that show an increase in longitudinal relaxivity, r(1), at ultra-high field strength relative to lower field strengths.

Image of tumor metastasis and inflammatory lymph node enlargement by contrast-enhanced ultrasonography

AIM: To compare the difference between tumor-induced lymph node enlargement and inflammation-induced lymph node enlargement by contrast-enhanced ultrasonography and pathological findings.

METHODS: A model of tumor-induced lymph node metastasis was prepared by embedding a VX2 tumor into the hind paws of white rabbits. A model of inflammation-induced enlargement was prepared by injecting a suspension of Escherichia coli into separate hind paws of white rabbits. Then, a solution of Sonazoid™ (GE Healthcare, Oslo, Norway) was injected subcutaneously in the proximity of the lesion followed by contrast-enhanced ultrasonography of the enlarged popliteal lymph nodes.

RESULTS: In the contrast-enhanced ultrasonography of the tumor-induced metastasis model, the sentinel lymph node was imaged. An area of filling defect was observed in that enlarged lymph node. In the histology examination, the area of filling defect corresponded to the metastatic lesion of the tumor. Contrast-enhanced ultrasonography of the model on inflammation-induced lymph node enlargement, and that of the acute inflammation model performed 3-7 d later, revealed dense staining that was comparatively uniform. The pathological findings showed acute lymphadenitis mainly due to infiltration of inflammatory cells. Contrast-enhanced ultrasonography that was performed 28 d post-infection in the acute inflammation model showed speckled staining. Inflammation-induced cell infiltration and fiberization, which are findings of chronic lymphadenitis, were seen in the pathological findings.

CONCLUSION: Sentinel lymph node imaging was made possible by subcutaneous injection of Sonazoid™. Contrast-enhanced ultrasonography was suggested to be useful in differentiating tumor-induced enlargement and inflammation-induced enlargement of lymph nodes.

Prospective trial evaluating sonography after thoracic surgery in postoperative care and decision making

OBJECTIVE

Following thoracic surgery, daily chest X-rays (CXRs) are performed to assess patient evolution and to make decisions regarding chest tube removal and patient discharge. Sonography after thoracic surgery (SATS) has the potential to be an effective, convenient, inexpensive and easy to learn tool in the post-operative management of thoracic surgery patients. We hypothesized that SATS could alleviate the need for repetitive CXRs, thus reducing the related risks, costs and inconvenience.

METHODS

This study consisted of a prospective cohort trial. All patients scheduled to undergo thoracic surgery at a single academic medical centre were eligible. Post-operative bedside pleural ultrasound was performed whenever a CXR was ordered by the treating team. Investigators specifically assessed patients with the goals of identifying pleural effusions and pneumothoraces. Study investigators were blinded to CXR results. SATS findings were compared with CXRs, which were considered the gold standard in routine post-operative pleural space evaluation.

RESULTS

One hundred and twenty patients were prospectively enrolled over a 5.5-month period. Three hundred and fifty-two ultrasound examinations were performed (mean = 3.0 ± 2.4 exams per patient). The time interval between the ultrasound and the comparative CXR was 166 ± 149 min. The mean time required to perform SATS was 11 ± 6 min per exam. In the detection of pleural effusion, SATS yielded a sensitivity of 83.1% and a specificity of 59.3%. In the detection of pneumothoraces, a sensitivity of 21.2% and a specificity of 94.7% were obtained.

CONCLUSIONS

Post-operative ultrasound may alleviate the need to perform routine CXR in patients with a previously ruled out pneumothorax. SATS used selectively may be able to reduce the number of routine CXRs performed; however, it does not have high enough accuracy to replace CXRs.

Hepatocellular carcinoma in 2011 and beyond: from the pathogenesis to molecular targeted therapy

Hepatocellular carcinoma is a malignant tumor responsible for approximately 600,000-700,000 deaths worldwide, and it is becoming more prevalent not only in Southeast Asia and Africa but also in Western countries; therefore, interest in hepatocellular carcinoma has mounted in recent years in the West, where little or no interest was evident 10-20 years ago.

Usefulness of combination of imaging modalities in the diagnosis of hepatocellular carcinoma using Sonazoid®-enhanced ultrasound, gadolinium diethylene-triamine-pentaacetic acid-enhanced magnetic resonance imaging, and contrast-enhanced computed tomography

OBJECTIVE

To clarify the diagnostic ability of combining imaging methods to diagnose hepatocellular carcinoma (HCC) using Sonazoid®-enhanced ultrasound (US), gadolinium diethylene-triamine-pentaacetic acid-enhanced (Gd-EOB-DTPA) magnetic resonance imaging (MRI), and contrast-enhanced computed tomography (CECT).

METHODS

A total of 32 patients who underwent surgical resection for HCC were studied. Sonazoid-enhanced US, Gd-EOB-DTPA MRI, CECT, and intraoperative contrast-enhanced ultrasonography were done for all patients. The definitive diagnosis of HCC in those patients was based on histopathological confirmation.

RESULTS

A total of 50 histologically proven HCCs were obtained from 32 patients; their mean (± SD) age was 68.3 years ± 8.1. The mean (± SD) nodule size was 2.6 cm ± 1.9. Twenty percent were well-differentiated HCC, 64% were moderately differentiated HCC, 10% were poorly differentiated HCC, 4% were combined HCC and CCC, and 2% were HCC with severe necrosis. The overall diagnostic sensitivity of CEUS, CECT, and Gd-EOB-DTPA MRI was 72, 74, and 86%, respectively; however, there was no significant difference between the three imaging modalities in diagnosing typical HCC (p = 0.092). When combining the diagnostic ability of the different imaging modalities, the diagnostic sensitivity of Sonazoid-enhanced US and Gd-EOB-DTPA MRI was 90%, while addition of Sonazoid-enhanced US to CECT and CECT to Gd-EOB-DTPA MRI had a sensitivity of 82 and 88%, respectively. There was no significant difference between the three imaging combinations (p = 0.970).

CONCLUSION

Sonazoid-enhanced US and Gd-EOB-DTPA MRI can be confidently used in daily clinical practice for the management of HCC.

Diagnostic imaging of hepatocellular carcinoma: recent progress

The diagnostic imaging of hepatocellular carcinoma (HCC) has recently undergone marked progress. The advent of the ultrasound (US) contrast agent Sonazoid, approved in January 2007, and magnetic resonance imaging (MRI) with the liver-specific MRI contrast agent gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA-MRI), approved in January 2008, are of particular significance. Sonazoid contrast-enhanced US (Sonazoid-CEUS) is useful not only for the diagnosis of HCC, but also for guiding treatment and assessing treatment response. Sonazoid-CEUS has proven to be particularly effective for screening and staging, which used to be considered impossible with CEUS, through the introduction of the newly developed diagnostic technique of defect reperfusion imaging. It is still not possible if other vascular agents such as SonoVue and Definity are used. In particular, Gd-EOB-DTPA-MRI has been suggested to be much more reliable in the differentiation of early HCC from precancerous dysplastic nodules than any other modalities such as multidetector raw computed tomography, dynamic MRI, and superparamagnetic iron oxide-MRI. A decrease in contrast uptake in the hepatocyte phase observed on EOB-MRI is strongly suggestive of cancer, and the absence of early staining in the arterial phase suggests early HCC. The differential diagnostic capacity of Gd-EOB-DTPA-MRI is considered to far exceed that of what were previously the most useful imaging techniques, computed tomography (CT) during hepatic arteriography or CT during arterial portography, and to be comparable to that of the pathological diagnosis by pathologists specialized in liver.

Comparison between nonspecific and necrosis-avid gadolinium contrast agents in vascular disrupting agent-induced necrosis of rodent tumors at 3.0T

OBJECTIVE

: To compare a commercial contrast agent (CA) Dotarem and a necrosis-avid CA (NACA) for their ability to evaluate the therapeutic necrosis with a vascular disrupting agent (VDA) on magnetic resonance imaging in rodent liver tumors to determine which could better correlate with the histopathologic outcome.

METHODS

: After the VDA treatment, 16 rats with 32 liver rhabdomyosarcomas were randomized into Dotarem and NACA groups (n = 8 per group) for both interindividual and intraindividual comparisons. T2-weighted imaging, T1-weighted imaging (T1WI), contrast-enhanced T1-weighted imaging (CE-T1WI), and diffusion-weighted imaging were performed at baseline, after VDA treatment and CA injections. The enhancing efficacy of CAs at immediate and delayed enhancement on CE-T1WI in viable tumor and necrosis was compared. Tumor necrosis ratios calculated from NACA and Dotarem were compared and correlated with gold-standard histopathology.

RESULTS

: On the immediate CE-T1WI, viable tumor was enhanced by either CA. On the delayed CE-T1WI at 30 minutes, both CAs failed to demarcate viable tumor from necrosis. At 24 hours post-NACA, the necrosis was clearly distinguished from viable tumor and thus derived necrosis ratio matched that from histopathology (P = 0.99); necrosis ratio from Dotarem was significantly lower than that from NACA and histopathology (P < 0.05, both), with a higher correlation of NACA than that of Dotarem with histopathology (r = 0.99 vs. r = 0.82).

CONCLUSIONS

: NACA better evaluated VDA-induced tumor necrosis than nonspecific CA on T1WI in tumor models of rat liver. NACA showed a closer correlation with histopathology than nonspecific CA for the delineation of true necrosis. Delayed enhancement on T1WI with nonspecific CA is not suitable for the assessment of VDA-induced tumor necrosis.

Review of dynamic contrast-enhanced ultrasound guidance in ablation therapy for hepatocellular carcinoma

Local ablative techniques-percutaneous ethanol injection, microwave coagulation therapy and radiofrequency ablation (RFA)-have been developed to treat unresectable hepatocellular carcinoma (HCC). The success rate of percutaneous ablation therapy for HCC depends on correct targeting of the tumor via an imaging technique. However, probe insertion often is not completely accurate for small HCC nodules, which are poorly defined on conventional B-mode ultrasound (US) alone. Thus, multiple sessions of ablation therapy are frequently required in difficult cases. By means of two breakthroughs in US technology, harmonic imaging and the development of second-generation contrast agents, dynamic contrast-enhanced harmonic US imaging with an intravenous contrast agent can depict tumor vascularity sensitively and accurately, and is able to evaluate small hypervascular HCCs even when B-mode US cannot adequately characterize the tumors. Therefore, dynamic contrast-enhanced US can facilitate RFA electrode placement in hypervascular HCC, which is poorly depicted by B-mode US. The use of dynamic contrast-enhanced US guidance in ablation therapy for liver cancer is an efficient approach. Here, we present an overview of the current status of dynamic contrast-enhanced US-guided ablation therapy, and summarize the current indications and outcomes of reported clinical use in comparison with that of other modalities.

Contrast-enhanced ultrasound for the diagnosis of hepatic adenoma

Nine hepatic adenomas (HA) diagnosed by contrast-enhanced ultrasound (CEUS) among 123 liver lesions (89 patients) were evaluated retrospectively; five were confirmed through pathological diagnosis. Time-intensity curves (TIC), contrast medium arriving time (AT), peak time (PT) and retrogression time (RT) for HA were compared with 30 hepatocellular carcinomas (HCC) and six focal nodular hyperplasias (FNH). Significant differences existed between HA and poorly-differentiated HCC in AT, PT and RT, and between HA and well-differentiated HCC in AT. Differential diagnosis between HA and FNH was determined only through their different perfusion and arterial morphological features: HA showed typical perfusion characteristic of 'fast-in, slow-out', with a centripetal or mixed-filling pattern in the arterial phase, while FNH showed a centrifugal filling pattern. In conclusion, CEUS was helpful for identifying HA but it may be relatively difficult to distinguish between HA and some well-differentiated HCC or FNH.

Usefulness of chest ultrasonography in detecting pulmonary embolism in patient with chronic obstructive pulmonary disease and chronic renal failure: a case report

We describe the case of a 75-year-old man affected by a chronic obstructive pulmonary disease and chronic renal failure admitted to our emergency department for dyspnea and interscapular stabbing pain. Chest radiography showed diffuse parenchymal consolidation in the lower right lung with bronchiectasis, but the treatment for infection disease did not improve the clinical conditions of the patient. According to Wells score indicating an intermediate risk for pulmonary embolism, we performed a chest ultrasonography that showed ultrasonographic patterns of thromboembolism. Because the presence of chronic renal failure limited the execution of a helical computed tomographic pulmonary angiography, a pulmonary scintigraphy was performed confirming the diagnosis of pulmonary embolism. Our case suggested that chest ultrasonography can be a valuable tool for early detection of pulmonary embolism and to establish immediately an appropriate therapy.

Lyso-thermosensitive liposomal doxorubicin: an adjuvant to increase the cure rate of radiofrequency ablation in liver cancer

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer death worldwide. No more than 30% of HCC patients are considered suitable for curative treatment because of tumor size and severity of liver impairment, among other factors. Radiofrequency ablation (RFA) monotherapy can cure small (<3 cm) HCC tumors. An adjuvant that interacts synergistically with RFA might enable curative therapy for many HCC patients with lesions >3 cm. Lyso-thermosensitive liposomal doxorubicin (LTLD) consists of the heat-enhanced cytotoxic doxorubicin within a heat-activated liposome. LTLD is infused intravenously prior to RFA. When heated to >39.5°C, LTLD releases doxorubicin in high concentrations into the tumor and the tumor margins. The RFA plus LTLD combination has shown a statistically significant dose-response effect for time to treatment failure in a Phase I trial in which most subjects (62.5%) had tumors >3 cm. RFA plus LTLD is currently being evaluated in a 600-patient randomized, double-blind, dummy-controlled trial.

Magnetic resonance enterography findings of chronic radiation enteritis

The diagnosis of chronic radiation enteritis (CRE) is considerably challenging both for clinicians and radiologists. The aim of this study was to evaluate the role of magnetic resonance enterography (MRE) in the diagnosis of CRE. To the best of our knowledge, there are no reports on the role of MRE in the diagnosis of CRE specifically. In this report, we present MRE findings of 4 patients with CRE. The most important factors in CRE diagnosis are the clinical findings and medical history, but focal abnormal bowel loop in the region of a known radiation field is the most important information. This abnormal loop is generally located in the distal ileum as present in our patients. Other associated findings helpful for the diagnosis are small bowel thickening, contrast material enhancement in a long segment, mesenteric stranding and luminal narrowing. MRE can be sufficient and useful in the diagnosis of CRE and for treatment planning, especially in patients with significant comorbidities who have had radiotherapy in the past. Adding MRE into the diagnostic algorithm can be helpful in post-radiotherapy patients with acute/subacute gastrointestinal symptoms.

Peripheral doses in patients undergoing Cyberknife treatment for intracranial lesions. A single centre experience

Background

Stereotactic radiosurgery/radiotherapy procedures are known to deliver a very high dose per fraction, and thus, the corresponding peripheral dose could be a limiting factor for the long term surviving patients. The aim of this clinical study was to measure the peripheral dose delivered to patients undergoing intracranial Cyberknife treatment, using the MOSFET dosimeters. The influence of the supplemental shielding, the number of monitor units and the collimator size to the peripheral dose were investigated.

Methods

MOSFET dosimeters were placed in preselected anatomical regions of the patient undergoing Cyberknife treatment, namely the thyroid gland, the nipple, the umbilicus and the pubic symphysis.

Results

The mean peripheral doses before the supplemental shielding was added to the Cyberknife unit were 51.79 cGy, 13.31 cGy and 10.07 cGy while after the shielding upgrade they were 38.40 cGy, 10.94 cGy, and 8.69 cGy, in the thyroid gland, the umbilicus and the pubic symphysis, respectively. The increase of the collimator size corresponds to an increase of the PD and becomes less significant at larger distances, indicating that at these distances the PD is predominate due to the head leakage and collimator scatter.

Conclusion

Weighting the effect of the number of monitor units and the collimator size can be effectively used during the optimization procedure in order to choose the most suitable treatment plan that will deliver the maximum dose to the tumor, while being compatible with the dose constraints for the surrounding organs at risk. Attention is required in defining the thyroid gland as a structure of avoidance in the treatment plan especially in patients with benign diseases.

[Emergency radiology: what clinicians expect from radiologists]

We review the relations between the radiology department and the clinicians that attend emergency patients, complementing our opinions with a survey conducted in the emergency departments of hospitals in the autonomous region of Madrid. A dedicated emergency radiology section is present in 63.2% of hospitals. Radiologists are readily available to consult in the emergency department in 100%. Radiologists are involved in the initial workup in 61% of hospitals, in follow-up in 22.3%, and in both the initial workup and follow-up in 16.7%. At least one common protocol is shared by radiologists and emergency clinicians in 73.7% of hospitals. Radiologists participate in deciding which imaging tests to perform in 78.9% of hospitals. Radiologists provide a written report of the examination in 83.3% of cases. Continual assessment of the relations between the emergency department and the radiology department will enable us to understand their dynamics and to know what aspects can be improved.

Ultrasonography in the management of the airway

In this study, it is described how to use ultrasonography (US) for real-time imaging of the airway from the mouth, over pharynx, larynx, and trachea to the peripheral alveoli, and how to use this in airway management. US has several advantages for imaging of the airway - it is safe, quick, repeatable, portable, widely available, and it must be used dynamically for maximum benefit in airway management, in direct conjunction with the airway management, i.e. immediately before, during, and after airway interventions. US can be used for direct observation of whether the tube enters the trachea or the esophagus by placing the ultrasound probe transversely on the neck at the level of the suprasternal notch during intubation, thus confirming intubation without the need for ventilation or circulation. US can be applied before anesthesia induction and diagnose several conditions that affect airway management, but it remains to be determined in which kind of patients the predictive value of such an examination is high enough to recommend this as a routine approach to airway management planning. US can identify the croicothyroid membrane prior to management of a difficult airway, can confirm ventilation by observing lung sliding bilaterally and should be the first diagnostic approach when a pneumothorax is suspected intraoperatively or during initial trauma-evaluation. US can improve percutaneous dilatational tracheostomy by identifying the correct tracheal-ring interspace, avoiding blood vessels and determining the depth from the skin to the tracheal wall.

Air in the heart: what should one do?

Air embolism is a serious and frequently underrecognized complication of vascular access device placement. Improper precautions during vascular catheter insertion result in inadvertent introduction of air into the vasculature. Systemic embolization into the cerebral, pulmonary, and coronary circulations can be catastrophic. We present a case of intracardiac air embolism after placement of a central venous catheter managed conservatively.

High-sensitivity in vivo THz transmission imaging of early human breast cancer in a subcutaneous xenograft mouse model

We performed in vivo THz transmission imaging study on a subcutaneous xenograft mouse model for early human breast cancer detection. With a THz-fiber-scanning transmission imaging system, we continuously monitored the growth of human breast cancer in mice. Our in vivo study not only indicates that THz transmission imaging can distinguish cancer from the surrounding fatty tissue, but also with a high sensitivity. Our in vivo study on the subcutaneous xenograft mouse model will encourage broad and further investigations for future early cancer screening by using THz imaging system.

Investigation of direct production of 68Ga with low energy multiparticle accelerator

Experimentally measured cross sections are presented for the natCu(α, xn)66,67,68Ga and 68Zn(p, xn)67,68Ga nuclear processes up to 36 and 20 MeV, respectively. Based on these results and the reliable cross section data available in the literature, the possible thick target yields were also calculated. Two different 68Ga production routes (Cu+α and Zn+p) are discussed in detail, especially with regard to the 66Ga and 67Ga contamination levels as a function of the target enrichment level and the incident bombarding energies. Both processes can be used for in-house 68Ga production with low (<1%) 66Ga and/or 67Ga EOB contamination using enriched 68Zn (>80%) or 65Cu (>95%) target. The maximum available yield on 100% enriched 68Zn and 65Cu (irradiation time: 2.25 h; bombarding energy: Ep=20 MeV and E α =18 MeV) is 352.45 mCi/μA (13.04 GBq/μA) and 14.28 mCi/μA (528.36 MBq/μA), respectively.

Difficult to control asthma in the patient with pseudoachondroplasia

Pseudoachondroplasia (PsA) is a type of short-limbed dwarfism resulting from mutations in the cartilage oligomeric matrix protein gene. Skeletal involvement in the PsA is well-described but there are not any published cases reporting airways involvement. The authors present a case of a female with the PsA and congenital anomalies of the respiratory tract resulting in the tracheobronchomalacia and a difficult to control asthma.

Focal therapy for prostate cancer - where are we in 2011?

Prostate cancer treatment is a controversial topic amongst physicians and patients alike. Radical therapies such as prostatectomy and whole gland radiation offer the best outcomes in terms of oncologic efficacy, but the decision to undergo treatment must be weighed against its potential morbidity. Over the past decade, the concept of focal therapy for prostate cancer has been introduced as a potential method of achieving oncologic control with a lesser degree of morbidity. Focal therapy refers to isolated ablation of a tumor focus with sparing of uninvolved, surrounding tissue. While it remains in the early stages of development, considerable research is underway that will help determine the optimal method of achieving this goal. Current areas of investigation include appropriate candidate selection, lesion identification, modality of treatment, and follow-up strategies.

Contrast-enhanced ultrasound in oncology

In patients with known malignant disease, 51% of liver lesions less than 1.5 cm turn out to be benign. Whether the probability of malignancy is high or low, further investigations are often necessary to definitely exclude malignancy. Contrast-enhanced ultrasonography has a prominent role in lesion characterization with a diagnostic accuracy comparable with computed tomography and magnetic resonance imaging. Anti-angiogenic treatment is common in most oncological institutions and the response evaluation is a new challenge with a research focus on the change in tumour vasculature and perfusion. In planning biopsies, CEUS can identify necrotic and viable areas of tumours and improve the diagnostic accuracy.

Differentiation of benign from malignant induced ascites by measuring gallbladder wall thickness

INTRODUCTION

There are multiple causes for ascites and conventional diagnostic method for most of them is paracentesis. This method is invasive and time consuming. The aim of this study is to survey the reliability of measuring gallbladder wall thickness to discriminate between cirrhotic and malignant ascites.

MATERIALS AND METHODS

In our study we measured the gallbladder wall thickness by ultrasonography in 100 consecutive patients with portal hypertension induced ascites and in 100 consecutive patients with peritoneal carcinomatosis induced ascites.

RESULTS

The mean Gallbladder wall thickness was 3.94±0.69 mm in cirrhotic patients and 2.26±0.62 mm in patients with peritoneal carcinomatosis. Gallbladder wall thickening in cirrhotic patients was significantly more compared to patients with peritoneal carcinomatosis (p-value=0.001).

CONCLUSION

This study shows that the thickened gallbladder wall in patients with ascites is highly predictive for diagnosis of portal hypertension induced ascites.

A pilot study of contrast harmonic endosonography using DEFINITY™ in the evaluation of suspected pancreatic and peri-ampullary malignancies

AIM: Contrast harmonic endosonography (CHEUS) is not widely available. This study assessed the utility of CHEUS using DEFINITY™, a second generation ultrasonic contrast agent, in the evaluation of suspected pancreatic and peri-ampullary malignancies. METHODS: Prospectively enrolled patients with suspected pancreatic and peri-ampullary malignancies underwent EUS followed by CHEUS. The incremental yield of CHEUS over EUS was analyzed. The gold standard for diagnosis of malignancy was positive cytology or histology; a negative diagnosis for malignancy was based on negative cytology or histology and benign clinical course. RESULTS: Twenty-nine patients were enrolled and underwent CHEUS. The final diagnoses were: pancreatic adenocarcinoma (16/29); metastases to pancreas (4/29); pancreatitis with inflammatory mass (4/29); normal pancreas with focal fat sparing (1/29); ampulla adenocarcinoma (2/29); serous cystic neoplasm (1/29); peri-pancreatic lymph node due to lymphoma (1/29). One bengin case of chronic pancreatitis had calcification casting artifacts that prevented accurate EUS examination and was excluded, leaving 28 cases for comparative analysis between EUS and CHEUS. CHEUS enhanced tumor margins. CHEUS detected vascular invasion missed by EUS in 2/16 patients with pancreatic adenocarcinoma. Masses appeared hypoechoic with EUS. With CHEUS malignant masses had an inhomogeneous hypoechoic pattern associated with abnormal vessels while lesions due to focal pancreatitis or fat sparing were characterized by diffuse enhancement (p<0.001). CONCLUSION: CHEUS improved the visualization of tumor margins and vascular invasion, and differentiated benign from malignant masses.

Differentiation between pancreatic carcinoma and mass-forming chronic pancreatitis: usefulness of high b value diffusion-weighted imaging

OBJECTIVE

To investigate the value of high b value diffusion-weighted (DW) imaging in differentiating between pancreatic carcinoma and mass-forming chronic pancreatitis (MFCP).

METHODS

Fifty-one consecutive patients with pathology-proven pancreatic carcinoma (n = 37) or MFCP (n = 14) were evaluated with DW imaging (b value, 0 and 1000 s/mm(2)) at a 3-T MR system. Overall 20 healthy volunteers were evaluated as the control group. The apparent diffusion coefficient (ADC) values of normal pancreas, pancreatic carcinoma, MFCP, and mass-associated obstructive pancreatitis were measured.

RESULTS

On high b value (1000 s/mm(2) ) DW images, both pancreatic carcinoma and MFCP were hyperintense focal lesions; mass-associated obstructive pancreatitis occurred in 17 of 37 (45.9%) pancreatic carcinoma and 8 of 14 (57.1%) MFCP. The ADC (×10(-3) mm(2) /s) of the pancreatic carcinomas (1.06 ± 0.15) was significantly lower than that of normal pancreas (1.47 ± 0.18; P < 0.01), MFCP (1.35 ± 0.14; P < 0.01) and mass-associated chronic pancreatitis (1.44 ± 0.17; P < 0.01). The ADC of MFCP was also lower than that in the normal pancreas (P = 0.025), whereas the ADC of mass-associated obstructive pancreatitis was not different from those of the MFCP (P = 0.113) and normal pancreas (P = 0.544). When 1.195 was used as the optimal cut-off value, ADC quantification obtained a sensitivity of 85.7% and a specificity of 86.5% for differentiating pancreatic carcinomas from MFCP.

CONCLUSION

High b value DW imaging in combination with ADC quantification at a 3-T MR system is useful in differentiating between pancreatic carcinoma and MFCP.

Genetic testing for early detection of individuals at risk of coronary heart disease and monitoring response to therapy: challenges and promises

Coronary heart disease (CHD) often presents suddenly with little warning. Traditional risk factors are inadequate to identify the asymptomatic high-risk individuals. Early identification of patients with subclinical coronary artery disease using noninvasive imaging modalities would allow the early adoption of aggressive preventative interventions. Currently, it is impractical to screen the entire population with noninvasive coronary imaging tools. The use of relatively simple and inexpensive genetic markers of increased CHD risk can identify a population subgroup in which benefit of atherosclerotic imaging modalities would be increased despite nominal cost and radiation exposure. Additionally, genetic markers are fixed and need only be measured once in a patient's lifetime, can help guide therapy selection, and may be of utility in family counseling.

Assessment of contralateral mammary gland dose in the treatment of breast cancer using accelerated hypofractionated radiotherapy

AIM: To measure the dose distribution, related to the treatment planning calculations, in the contralateral mammary gland of breast cancer patients treated with accelerated hypofractionated 3-dimensional conformal radiotherapy.

METHODS: Thirty-four prospectively selected female patients with right breast cancer (pN0, negative surgical margins) were treated with breast-conserving surgery. A total dose of 42.5 Gy (2.66 Gy/fraction) was prescribed; it was requested that planning target volumes be covered by the 95% isodose line. The contralateral mammary gland was defined on CT simulation. The dose received was evaluated by dose volume histograms.

RESULTS: The measured contralateral breast doses were: (1) Dose maximum: 290-448 cGy [Equivalent (Eq) 337-522 cGy]; (2) Mean dose: 45-70 cGy (Eq 524-815 cGy); and (3) Median dose: 29-47 cGy (337-547 cGy) for total primary breast dose of 42.5 Gy in 16 equal fractions. The spearman rho correlation showed statistical significance between the contralateral breast volume and maximum dose (P = 0.0292), as well as mean dose (P = 0.0025) and median dose (P = 0.046) to the breast.

CONCLUSION: Minimizing the dose to the contralateral breast has to be one of the priorities of the radiation oncologist when using short schedules because of the radiosensitivity of this organ at risk. Further study is necessary to assess the long-term clinical impact of this schedule.

A careful evaluation of scout CT lateral radiograph may prevent unreported vertebral fractures

OBJECTIVES

Our purpose was to review scout CT lateral radiographs to reveal osteoporotic vertebral fractures unreported by radiologists and to explore scout CT as a potential diagnostic tool in the detection of vertebral fractures.

METHODS

We considered 500 patients (303 males, 197 females, age 64.6±13.5 year-old). Our investigation was firstly focused on scout CT lateral images to detect vertebral fractures with a combined semiquantitative and quantitative diagnostic approach. Findings addressed to vertebral fracture were subsequently confirmed by multiplanar sagittal CT reconstructions. Whenever a vertebral fracture was discovered the radiologist report was read and a collection of patient anamnesis followed to understand whether fractures were already known.

RESULTS

In 44/500 patients (8.8%) the evaluation on scout CT was incomplete or limited for patient/technical-based conditions, and 15 were excluded from the analysis. In 67/485 patients (13.8%) 99 vertebral fractures were detected. Among 67 fractured patients only 18 (26.9%) were previously diagnosed by radiologists. However, in the clinical history of 32 patients vertebral fractures were already known.

CONCLUSIONS

The perception and sensibility to vertebral fractures among radiologists are still poor when the assessment of the spine is not the aim of the examination. Short time spent for the evaluation of scout CT lateral radiographs could improve our accuracy.

Radiofrequency ablation for the treatment of hepatocellular carcinoma with decompensated cirrhosis

BACKGROUND

Radiofrequency ablation (RFA) is used to treat early-stage hepatocellular carcinoma (HCC), but is sometimes avoided in patients with decompensated liver cirrhosis because of the possible side effect of deterioration of liver function.

AIMS

In this study, we report the safety and effects of RFA for treating HCC patients with Child-Pugh B/C liver cirrhosis.

METHODS

Sixty-six consecutive HCC patients with Child-Pugh B/C cirrhosis, who were treated by RFA, were enrolled in this study. We analyzed patient outcomes, the complications of RFA, and changes in liver function and tumor markers.

RESULTS

Fifty-six patients were classified as Child-Pugh class B, and 10 were classified as class C. The overall survival rates in patients with Child-Pugh B and C cirrhosis were 82 and 83% at 1 year and 47 and 31% at 3 years, respectively. Serum total bilirubin (T.Bil), albumin, prothrombin time, ascites, and encephalopathy were unchanged at 1, 3, and 6 months after RFA in patients with Child-Pugh B cirrhosis; however, serum T.Bil levels increased significantly at 6 months after RFA in 6/10 (60%) patients with Child-Pugh C cirrhosis. Hemothorax and rupture of esophageal varices were observed in 2 patients; however, there were no complications related to poor liver function.

CONCLUSION

RFA is a useful modality for treating HCC in patients with poor liver function such as Child-Pugh B and C, but careful monitoring after RFA must be needed.

EUS for diagnosis of malignant biliary stricture: an analysis of 13 cases

AIM: To compare the clinical value of endoscopic ultrasonography (EUS), endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance cholangiopancreatography (MRCP) in the diagnosis of malignant biliary stricture.

METHODS: The imaging data for 76 patients with malignant biliary stricture who underwent EUS, ERCP or MRCP from January 2008 to May 2010 were retrospectively analyzed. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of each test were compared.

RESULTS: EUS had significantly higher sensitivity (94.2% vs 78.5%), specificity (84.6% vs 57.1%), positive predictive value (89.1% vs 64.5%), negative predictive value (73.3% vs 41.3%) and accuracy (91.6% vs 71.6%) than MRCP in the diagnosis of malignant biliary stricture. EUS had significantly higher sensitivity (94.2% vs 80.5%), specificity (84.6% vs 68.4%) and accuracy (91.6% vs 71.6%) than ERCP in the diagnosis of malignant biliary stricture.

CONCLUSION: EUS has higher sensitivity, specificity and accuracy than MRCP and ERCP in the diagnosis of malignant biliary stricture.

Effect of SonoVue on the synovial membrane in rabbit knees

OBJECTIVES

The purpose of this study was to evaluate the effect of intra-articular injection of SonoVue (sulfur hexafluoride with a phospholipid shell; Bracco SpA, Milan, Italy) on the synovial membrane in an animal model.

METHODS

Twenty-one New Zealand White rabbits (42 knees) were used in this study. We injected the knees with normal saline (saline group; n = 21) and SonoVue (SonoVue group; n = 21). A histologic examination of the knees was performed out at 3 and 12 hours and 3, 7, 15, 30, and 45 days after injection. Four histologic parameters (synovial hyperplasia, synovial stroma, vascular dilatation, and inflammatory infiltrates) were graded separately.

RESULTS

We found no significant differences in this study for synovial hyperplasia, vascular dilatation, or inflammatory infiltrates between the saline and SonoVue groups. A significant difference was only observed for synovial stroma (P < .05), and most of the histologic changes were mild in the saline group and moderate in the SonoVue group. The histologic changes observed in this study are considered transitory and reversible.

CONCLUSIONS

The results suggest that intra-articular injection of SonoVue is a safe procedure.

Poul Erik Andersen's radiological work on Osteochondrodysplasias and interventional radiology

Poul Erik Andersen is a Professor and Interventional Radiologist at the University of Southern Denmark, Odense and Odense University Hospital, Denmark. His innovative and expertise is primarily in vascular interventions where he has introduced and developed many procedures at Odense University Hospital. His significant experience and extensive scientific work has led to many posts in the Danish Society of Interventional Radiology, the European Society of Radiology and the Cardiovascular and Interventional Radiological Society of Europe, where he is a fellow and has passed the European Board of Interventional Radiology - The European qualification in Interventional Radiology.

[Malignant focal liver lesions]

Focal liver lesions are a very common occurrence. The detection and differentiation of such lesions is particularly important for the management of oncology patients and is a core task for radiology. The early and conclusive detection of malignant liver processes in a cost-efficient manner and with a low radiation dose for the patient requires systematic and skillful use of the various radiological methods. This review explains the application of current radiological methods for the detection and differentiation of malignant liver lesions and the typical appearance of the most commonly found liver malignancies.

Assessment and characterisation of common renal masses with CT and MRI

Objective

Owing to the widespread use of abdominal imaging studies the detection rate of solid renal masses has increased, and an accurate characterisation of imaging features of renal masses has become more essential for case management.

Method and results

MR imaging (MRI) and computed tomography (CT) are frequently used modalities for detection and differentiation of renal masses. This article gives a review of imaging characteristics of benign and malignant renal masses, discussing their appearance in CT and MR imaging. Advanced MR techniques like diffusion-weighted imaging and apparent diffusion coefficient (ADC) mapping, which have shown promising results in the differentiation between benign and malignant renal lesions, will be introduced.

Conclusion

MRI and CT are useful in the characterisation and estimation of the prognosis for renal masses.

Radiofrequency ablation of hepatocellular carcinoma: Current status

Ablation therapy is one of the best curative treatment options for malignant liver tumors, and can be an alternative to resection. Radiofrequency ablation (RFA) of primary and secondary liver cancers can be performed safely using percutaneous, laparoscopic, or open surgical techniques, and RFA has markedly changed the treatment strategy for small hepatocellular carcinoma (HCC). Percutaneous RFA can achieve the same overall and disease-free survival as surgical resection for patients with small HCC. The use of a laparoscopic or open approach allows repeated placements of RFA electrodes at multiple sites to ablate larger tumors. RFA combined with transcatheter arterial chemoembolization will make the treatment of larger tumors a clinically viable treatment alternative. However, an accurate evaluation of treatment response is very important to secure successful RFA therapy. Since a sufficient safety margin (at least 0.5 cm) can prevent local tumor recurrences, an accurate evaluation of treatment response is very important to secure successful RFA therapy. To minimize complications of RFA, clinicians should be familiar with the imaging features of each type of complication. Appropriate management of complications is essential for successful RFA treatment.

A steroid-conjugated magnetic resonance probe enhances contrast in progesterone receptor expressing organs and tumors in vivo

Progesterone receptor (PR) is a significant biomarker in diseases such as endometriosis and breast, ovarian, and uterine cancers that is associated with disease prognosis and therapeutic efficacy. While receptor status is currently determined by immunohistochemistry assays, the development of noninvasive PR imaging agents could improve molecular characterization, treatment decisions, and disease monitoring. ProGlo, a progesterone-conjugated magnetic resonance imaging (MRI) contrast agent, was evaluated in vivo to determine whether it targets and enhances signal intensity in organs and tumors that express high PR levels. A tissue distribution study indicated that ProGlo accumulates in the PR-rich uterus, which was confirmed by in vivo imaging studies. Ex vivo images of these organs revealed that ProGlo was distributed in the substructures that express high PR levels. In xenograft tumor models, ProGlo was taken up to a greater extent than the nonfunctionalized Gd-DO3A in tumors, particularly in PR(+) tumors. The ability to accumulate and enhance signal intensity in PR(+) organs and tumors suggests that ProGlo may be a promising MRI probe for PR(+) diseases.

Pathological and MR-DWI study of the acute hepatic injury model after stem cell transplantation

AIM: To investigate apparent diffusion coefficient (ADC) values as an indication of reconditioning of acute hepatic injury (AHI) after allogeneic mononuclear bone marrow cell (MBMC) transplantation.

METHODS: Three groups were used in our study: a cell transplantation group (n = 21), transplantation control group (n = 21) and normal control group (n = 10). AHI model rabbits in the cell transplantation group were injected with 5 mL of MBMC suspension at multiple sites in the liver and the transplantation controls were injected with 5 mL D-Hanks solution. At the end of the 1st, 2nd and 4th wk, 7 rabbits were randomly selected from the cell transplantation group and transplantation control group for magnetic resonance diffusion-weighted imaging (MR-DWI) and measurement of the mean ADC values of injured livers. After MR-DWI examination, the rabbits were sacrificed and the livers subjected to pathological examination. Ten healthy rabbits from the normal control group were used for MR-DWI examination and measurement of the mean ADC value of normal liver.

RESULTS: At all time points, the liver pathological scores from the cell transplantation group were significantly lower than those in the transplantation control group (27.14 ± 1.46 vs 69.29 ± 6.16, 22.29 ± 2.29 vs 57.00 ± 1.53, 19.00 ± 2.31 vs 51.86 ± 6.04, P = 0.000). The mean ADC values of the cell transplantation group were significantly higher than the transplantation control group ((1.07 ± 0.07) × 10^-3 mm²/s vs (0.69 ± 0.05) × 10^-3 mm²/s, (1.41 ± 0.04) × 10^-3 mm²/s vs (0.84 ± 0.06) × 10^-3 mm²/s, (1.68 ± 0.04) × 10^-3 mm²/s vs (0.86 ± 0.04) × 10^-3 mm²/s, P = 0.000). The pathological scores of the cell transplantation group and transplantation control group gradually decreased. However, their mean ADC values gradually increased to near that of the normal control. At the end of the 1st wk, the mean ADC values of the cell transplantation group and transplantation control group were significantly lower than those of the normal control group [(1.07 ± 0.07) × 10^-3 mm²/s vs (1.76 ± 0.03) × 10^-3 mm²/s, (0.69 ± 0.05) × 10^-3 mm²/s vs (1.76 ± 0.03) × 10^-3 mm²/s, P = 0.000]. At any 2 time points, the pathological scores and the mean ADC values of the cell transplantation group were significantly different (P = 0.000). At the end of the 1st wk, the pathological scores and the mean ADC values of the transplantation control group were significantly different from those at the end of the 2nd and 4th wk (P = 0.000). However, there was no significant difference between the 2nd and 4th wk (P = 0.073 and 0.473, respectively). The coefficient of correlation between the pathological score and the mean ADC value in the cell transplantation group was -0.883 (P = 0.000) and -0.762 (P = 0.000) in the transplantation control group.

CONCLUSION: Tracking the longitudinally dynamic change in the mean ADC value of the AHI liver may reflect hepatic injury reconditioning after allogeneic MBMC transplantation.