Contrast-enhanced ultrasonography of hepatocellular carcinoma: correlation between quantitative parameters and arteries in neoangiogenesis or sinusoidal capillarization

Analysis of early response to chemotherapy for non-Hodgkin's lymphoma by quantitative contrast-enhanced ultrasound: A prospective case-control crossectional study

OBJECTIVE

To investigate the value of quantitative contrast-enhanced ultrasonography (CEUS) in assessing and predicting early therapy response of non-Hodgkin's lymphoma (NHL).

METHODS

Fifty-six cases of NHL were studied using CEUS before and after three cycles of R-CHOP / CHOP. Quantitative parameters such as arrival time (ATM), time to peak (TTP), △T = TTP-ATM, area under the gamma curve (Area), curve gradient (Grad), wash-out time (WT), base intensity (BI), peak intensity (PI) and ΔI = PI-BI were compared between the lymphoma and normal lymph nodes before and at mid-treatment, respectively. Changes in quantitative CEUS parameters were also compared between complete response (CR) and incomplete response(non-CR) groups. Besides, the correlation analysis was performed between pretreatment PI and changes in quantitative parameters.

RESULTS

After three cycles of R-CHOP/CHOP, S/L (P < 0.001), PI (P = 0.002), ΔI (P < 0.001), Grad (P < 0.001), and Area (P < 0.001) of NHL were significantly decreased. The CR group and non-CR group only differed in ATM before treatment. In contrast, there was no statistical difference in any of the parameters between the two groups at mid-treatment. Finally, a significant correlation was observed between pre-treatment PI and PI△% (r = 0.736, P < 0.001).

CONCLUSIONS

CEUS is promising for the assessment of response of NHL to R-CHOP/CHOP. Intra-lesion perfusion changes take precedence over morphological changes suggesting treatment efficacy. Pre-treatment ATM values may help to suggest efficacy outcomes and pre-treatment PI values may be a valid predictor of lymphoma perfusion response.

Discrepancy of contrast-enhanced ultrasonographic pattern with two contrast agents in steatohepatitic subtype hepatocellular carcinoma: A case report

Contrast-enhanced ultrasound (CEUS) is one of the important imaging modalities for diagnosis of hepatocellular carcinoma (HCC). Sonovue and Sonazoid are the third-generation of ultrasound contrast agents that have been commercialized and widely used in clinical applications. This study introduces the imaging differences between these two agents in vascular phases for the first time. A 54-year-old man clinical suspected liver cancer. He had chronic hepatitis B for more than 20 years. The result of alpha-fetoprotein was 36.45μg/L (normal< 20μg/L). The imaging pattern of CEUS with Sonovue was “fast-in and fast-out” performance, while the pattern of “fast-out” was absent after portal phase with Sonazoid, even in Kupffer phase. The lesion was diagnosed as lipid-rich HCC by contrast-enhanced MRI. After liver resection, pathology revealed that it was hepatocellular carcinoma contained poor-differentiated steatohepatitis subtype and moderate-differentiated microtrabecular subtype. The imaging difference mainly existed in the part of steatohepatitis subtype. Steatohepatitis subtype HCC can be showed as “fast-in and no wash-out” characteristic in Sonazoid CEUS. Though the mechanism remains not fully clarified, this different enhancing pattern may provide a potential for the supplement of the guidelines and differential of steatohepatitis subtype HCC.

Quantitative Analysis of the Time-Intensity Curve of Contrast-Enhanced Ultrasound of the Liver: Differentiation of Benign and Malignant Liver Lesions

Background: To evaluate the diagnostic accuracy of quantitative perfusion parameters in contrast-enhanced ultrasound to differentiate malignant from benign liver lesions. Methods: In this retrospective study 134 patients with a total of 139 focal liver lesions were included who underwent contrast enhanced ultrasound (CEUS) between 2008 and 2018. All examinations were performed by a single radiologist with more than 15 years of experience using a second-generation blood pool contrast agent. The standard of reference was histopathology (n = 60), MRI or CT (n = 75) or long-term CEUS follow up (n = 4). For post processing regions of interests were drawn both inside of target lesions and the liver background. Time–intensity curves were fitted to the CEUS DICOM dataset and the rise time (RT) of contrast enhancement until peak enhancement, and a late-phase ratio (LPR) of signal intensities within the lesion and the background tissue, were calculated and compared between malignant and benign liver lesion using Student’s t-test. Quantitative parameters were evaluated with respect to their diagnostic accuracy using receiver operator characteristic curves. Both features were then combined in a logistic regression model and the cumulated accuracy was assessed. Results: RT of benign lesions (14.8 ± 13.8 s, p = 0.005), and in a subgroup analysis, particular hemangiomas (23.4 ± 16.2 s, p < 0.001) differed significantly to malignant lesions (9.3 ± 3.8 s). The LPR was significantly different between benign (1.59 ± 1.59, p < 0.001) and malignant lesions (0.38 ± 0.23). Logistic regression analysis with RT and LPR combined showed a high diagnostic accuracy of quantitative CEUS parameters with areas under the curve of 0.923 (benign vs. malignant) and 0.929 (hemangioma vs. malignant. Conclusions: Quantified CEUS parameters are helpful to differentiate malignant from benign liver lesions, in particular in case of atypical hemangiomas.

Early prediction of response to neoadjuvant chemotherapy using contrast-enhanced ultrasound in breast cancer

Early prediction of non-response is essential in order to avoid inefficient treatments. The objective of this study was to determine the contrast-enhanced ultrasound (CEUS) for early predicting pathologic complete response (pCR) to neoadjuvant chemotherapy (NAC) in breast cancer patients.Between March 2018 and October 2019, 93 consecutive patients with histologically proven breast cancer scheduled for NAC were enrolled. Conventional ultrasound and CEUS imaging were performed before NAC and after two cycles of NAC. CEUS parameters were compared with pathologic response. Multiple logistic regression analyses were utilized to explore CEUS parameters to predict pCR, and receiver operating characteristic analysis was used to evaluate the predictive ability.Therapeutic response was obtained from 25 (27%) patients with pCR and 68 (73%) with non-pCR. Compared to non-pCR, pCR cases have a significantly higher proportion of homogeneous enhancement feature (56% vs 14%, P < .001) and centripetal enhancement (52% vs 23%, P = .012). A significant decrease in peak intensity (PI) was observed after two cycles of NAC. Compared with non-pCR patients, the kinetic parameters PI change (PI%) was higher in pCR patients (P < .001). Multiple logistic regression demonstrated two independent predictors of pCR: internal homogeneity (odds ratio, 4.85; 95% confidence interval: 1.20-19.65; P = .027) and PI% (odds ratio, 1.08; 95% confidence interval: 1.02-1.15; P = .007). In receiver operating characteristic curve analysis, internal homogeneity and PI%, with area under curve of 0.71 and 0.84, predicted pCR with sensitivity (56%, 95%) and specificity (85%, 70%), respectively.Internal homogeneity and PI% of CEUS may be useful in the noninvasive early prediction of pCR in patients with breast cancer.

A fuzzy clustering based color-coded diagram for effective illustration of blood perfusion parameters in contrast-enhanced ultrasound videos

BACKGROUND AND OBJECTIVE

Early identification and diagnosis of tumors are of great significance to improve the survival rate of patients. Amongst other techniques, contrast-enhanced ultrasound is an important means to help doctors diagnose tumors. Due to the advantages of high efficiency, accuracy and objectivity, more and more computer-aided methods are used in medical diagnosis. Here we propose, a color-coded diagram based on quantitative blood perfusion parameters for contrast-enhanced ultrasound video. The method realizes the static description of the dynamic blood perfusion process in contrast-enhanced ultrasound videos and reveal the blood perfusion characteristics of all regions of the tissue providing assistance to the doctors in their clinical diagnosis.

METHODS

For effective illustration of the blood perfusion through tissues, we propose (a) an improved block matching algorithm to eliminate the image distortions caused by breathing; (b) compute the time-grayscale intensity curve for each pixel to obtain four different quantitative blood perfusion parameters; and finally (c) employ the fuzzy C-means clustering algorithm to cluster the blood perfusion parameters, where each parameter is associated with a particular color. Thus based on the correspondence between the pixel and the blood perfusion parameters, all the pixels are color-coded to obtain the color-coded diagram.

RESULTS

To the best of our knowledge, the proposed technique is one-of-its-kind to color code the contrast-enhanced ultrasound videos using blood perfusion parameters in order to understand the hemodynamic characteristics of the benign and malignant lesion. In our experiments, various contrast-enhanced ultrasound videos corresponding to several real-world cases were color-coded and the results of the experiments illustrated that the proposed color-coded diagrams are consistent with the diagnosis presented by the physicians.

CONCLUSIONS

The experimental results suggested that the proposed method can comprehensively describe the blood perfusion characteristics of tissues during the angiography process thereby effectively assisting the doctors in diagnosis.

Correlations between quantitative parameters of contrast-enhanced ultrasound and vasculogenic mimicry in murine tumor model: a novel noninvasive technique for assessment?

Objective

Vasculogenic mimicry (VM) is a novel mechanism of tumor blood supply distinct from endothelial vessel (EV). VM is associated with malignancy, invasion, metastasis, and poor prognosis. Hitherto a noninvasive method for the assessment of VM in vivo has been lacking.

Methods

Contrast-enhanced ultrasound (CEUS) was performed to evaluate the quantitative parameters of tumors in mice. CD31 immunohistochemistry-Periodic Acid-Schiff double staining was conducted to identify the VM or EV in tumor tissues. Correlations between perfusion parameters and VM density was analyzed by Pearson correlation test.

Results

By the 15th day after tumor inoculation, the EV and VM density was 31.15 ± 7.14 and 14.11 ± 2.99 per 200× field. The maximal intensity (IMAX) was 301.19 ± 191.56%, and the rise time (RT), time to peak (TTP) and mean transit time (mTT) were 17.38 ± 7.82 s, 20.27 ± 9.61 s and 58.09 ± 26.44 s, respectively. VM density positively correlated to RT (r = 0.3598, P = 0.0226), TTP (r = 0.3733, P = 0.0177) and mTT(r = 0.6483, P <  0.0001), whereas EV density positively correlated to IMAX (r = 0.4519, P = 0.0034). The vascular diameter of VM was substantially larger than that of EV (43.81 ± 5.88 μm vs 11.21 ± 4.13 μm).

Conclusion

Three quantitative parameters related to VM were obtained and the relationships between CEUS and VM were established. CEUS might thus provide a novel noninvasive method to assess VM in vivo.

Contrast-Enhanced Ultrasound in Residual Tumor of Hepatocellular Carcinoma following Transarterial Chemoembolization: Is It Helpful for Tumor Response?

Aim

To investigate the enhancement pattern of residual tumor on contrast-enhanced ultrasonography (CEUS) in patients with hepatocellular carcinoma (HCC) treated with transarterial chemoembolization (TACE).

Methods

Our study initially included 76 patients with HCC, 73 of which were finally allocated into two groups: group 1 (43 patients, post-TACE group) and group 2 (30 patients, untreated HCC group). All patients were performed with CEUS using SonoVue, and qualitative and quantitative enhancement characteristics (rise time, peak time, and washout time) were evaluated for the residual tumors. T test or χ2 test was used to estimate for differences between two groups.

Results

In group 1, the mean rise time, peak time, and washout times in group 1 were 16.1±2.7 sec, 31.3±3.1 sec, and 191.0±31.3 sec, respectively. In group 2, these were 15.1±3.5 sec, 30.9±3.2 sec, and 142.6±16.1 sec, respectively. The differences in rise time and peak time were not statistically significant (P=0.09 and 0.30, respectively), but the washout time was significantly prolonged in group 1 (P<0.01). The enhanced pattern in arterial phase was inhomogeneous (n=11), regular homogeneous (n=11), partial (n=12), peripheral (n=7), and peripheral rim-like (n=2) in group 1. The average of the longest tumor size of the whole lesion in the 5 types was 4.7±1.3cm, 2.9±1.0cm, 3.1±1.7cm, 2.5±0.6cm, and 2.1 cm.

Conclusion

It suggested that the washout time of post-TACE residual lesions was prolonged compared with untreated HCC nodules on CEUS imaging. Combined with the triple-phase enhancement pattern seen on CEUS, the washout time may provide additional information to guide further treatment for residual tumors.

Comparison of Contrast-Enhanced Ultrasound and Positron Emission Tomography/Computed Tomography (PET/CT) in Lymphoma

Background

This study aimed to assess the value of contrast-enhanced ultrasound (CEUS) in the diagnosis and prognosis of lymphoma based on PET-CT.

Material/Methods

Our study included 88 superficial lymph nodes and 63 patients who underwent ultrasound-guided biopsy or surgery for pathology from October 2015 to March 2017. All lymph nodes were assessed by CEUS and PET-CT. CEUS and PET-CT parameters were recorded, including arrive time (AT), time to peak (TTP), base intensity (BI), peak intensity (PI), ascending slope (AS), descending slope (DS), area under the TIC curve (AUC), maximum standardized uptake value (SUVmax), and mean standardized uptake value (SUVmean). Pearson’s correlation was used to assess the associations of CEUS and PET-CT parameters.

Results

Of the 88 lymph nodes examined,12 were Hodgkin’s lymphoma (HL) and76 were non-Hodgkin’s lymphoma (NHL). The variations of CEUS dose parameters (ΔI, AUC, and AS) were positively correlated with PET-CT results (SUVmax and TLG). Correlation coefficients were 0.609, 0.518, 0.456, 0.630, 0.593, and 0. 532, respectively. The remaining time values (AT, TP, and ΔT) were negatively associated with PET-CT results. Correlation coefficients were −0.239, −0.272, −0.284and −0.377, −0.391, and −0.320, respectively.

Conclusions

Quantitative CEUS data were correlated with PET-CT values, with potential use in the diagnosis of lymphoma.

Value of contrast-enhanced ultrasound and PET/CT in assessment of extramedullary lymphoma

OBJECTIVE

The aim of the study was to evaluate clinical value of contrast-enhanced ultrasonography (CEUS) and PET/CT for assessment of extramedullary lymphoma, using histopathology as reference standard.

METHOD

A total of 63 patients with histopathologically-confirmed extramedullary lymphoma who had underwent CEUS and PET/CT examinations of suspicious lymph nodes included in the study. CEUS patterns and parameters (arrival time, peak time and intensity, base intensity, area under the time-intensity curve, ascending and descending slopes) and PET/CT parameters including maximum standardized uptake value, mean standardized uptake value, and metabolic tumor volume (MTV) were evaluated. Patients were classified into Hodgkin lymphomas (HL), non-Hodgkin lymphomas (NHL), early (stage I and II) and advanced (stage III and IV) lymphoma, B cells and T cells lymphoma, and aggressive and indolent lymphoma. The differences between the two independent samples were compared using non-parametric rank and inspection, P < 0.05 was considered statistically significant. The optimal cut-off value for parameters was used to predict the staging and pathology using Receiver Operating Characteristic (ROC) curve analysis.

RESULT

In the early and advanced group, the differences between △T and ascending slope (AS) were statistically significant (p = 0.010, 0.024 < 0.05). Hodgkin lymphomas (HL) or non-Hodgkin lymphomas (NHL) results were determined by optimal cut-off value of AT and TP (p = 0.001, 0.001 < 0.05). Aggressive or indolent lymphoma were determined by optimal cut-off values of Color Doppler flow resistance index (P = 0.001 < 0.05) and SUVmax (p = 0.001 < 0.05). There was no statistically significant difference between B and T cell lymphoma. And there was no statistically significant difference among the qualitative indexes. The optimal cutoff value for statistically significant indicators was calculated by ROC.

CONCLUSION

The quantitative parameters of CEUS and SUVmax of PET/CT are proven useful in assessment of different clinical and pathologic patterns of extramedullary lymphoma.

Parameters for Contrast-Enhanced Ultrasound (CEUS) of Enlarged Superficial Lymph Nodes for the Evaluation of Therapeutic Response in Lymphoma: A Preliminary Study

BACKGROUND The aims of this preliminary study were to evaluate contrast-enhanced ultrasound (CEUS) imaging and the therapeutic response of enlarged superficial lymph nodes in patients with lymphoma before and after chemotherapy and to determine the most useful CEUS response parameters. MATERIAL AND METHODS Forty-three patients with lymphoma, with 43 enlarged superficial lymph nodes, underwent CEUS and conventional ultrasound (US), before treatment and after the first three cycles of chemotherapy. Clinical responses included overall response (OR) and no response (NR). Imaging parameters by time-intensity curve (TIC) included basic intensity (B), wash-out slope and/or decent slope (K), wash-in slope or rise slope (C), time to peak (TTP), area under the gamma curve (Area), arrive time(ATM), peak intensity (PI), change of peak intensity (I) were compared. And receiver operating characteristic (ROC) curve analysis was operated. RESULTS Quantitative parameters of CEUS before and after the first three cycles of chemotherapy showed a significant difference in the AreaΔ, PID, and IΔ in the OR group compared with NR group (P<0.05). There was a significant difference in the Cpre, Areain, PIin, Iin, AreaΔ, PIΔ, and IΔ in the OR group compared with NR group (P<0.05). The effectiveness of the therapeutic response was predicted by the CEUS parameters of IΔ (P<0.05). And ΔArea has the highest diagnostic performance of ineffectiveness. CONCLUSIONS The findings of this study have shown that quantitative analysis by CEUS may be a useful, and objective, imaging method for the evaluation of the therapeutic response of enlarged superficial lymph nodes in lymphoma before and after chemotherapy.

Key role of liver sinusoidal endothelial cells in liver fibrosis

Because of the prevalence of viral hepatitis and nonalcoholic fatty liver disease (NAFLD), liver fibrosis has become a very common disease in Asia and elsewhere in the world, constantly increasing the burden of care borne by society. Hepatic sinusoidal capillarization, characterized by gradually shrinking fenestrae on the surface of liver sinusoidal endothelial cells (LSECs) and the formation of an organized basement membrane, is an initial pathologic change associated with liver fibrosis. Basic and clinical studies have indicated that LSECs play a key role in hepatic sinusoidal capillarization by affecting various aspects of the development and progression of liver fibrosis. Reviewing studies on the effect of LSECs on liver fibrosis is essential to better understanding the pathogenesis of liver fibrosis and its mechanism of progression. Moreover, such a review will provide a theoretical basis for identifying new methods to promote the regression or even inhibition of fibrosis. This review will focus on structural and functional changes in LSECs during hepatic sinusoidal capillarization and the interaction between the micro-environment of the liver and the body's immune system.

Contrast-enhanced ultrasonography of cervical carcinoma: perfusion pattern and relationship with tumour angiogenesis

OBJECTIVE

This study aimed to investigate the use of contrast-enhanced ultrasonography (CEUS) and time-intensity curves to assess angiogenesis in cervical cancer.

METHODS

60 patients who were scheduled to undergo radical surgery for biopsy-proven cervical cancers underwent CEUS. Surgical tissue sections from 32 patients who did not receive neoadjuvant chemotherapy were analyzed with CD34 staining to estimate intratumoral microvessel density (MVD). CEUS images were analyzed for maximum intensity (IMAX), rise time (RT), time to peak (TTP) and mean transit time.

RESULTS

Cervical lesions had a higher IMAX and shorter RT and TTP (p < 0.001) than reference regions. There was a linear association between the IMAX of the cervical lesion and the mean intratumoral MVD (r = 0.624, p < 0.001). There were no significant differences in CEUS variables according to histological type, grade and stage.

CONCLUSION

Quantitative CEUS variables have potential use for monitoring perfusion changes in tumours after non-surgical therapy for advanced cervical cancer.

ADVANCES IN KNOWLEDGE

The article demonstrates the capability and value of quantitative CEUS as a non-invasive strategy for detecting the perfusion and angiogenic status of cervical cancer. Quantitative CEUS variables have potential use for monitoring tumour response to non-surgical therapy.

The Value of Contrast-Enhanced Ultrasound in the Diagnosis of Cesarean Scar Pregnancy

Objective. To evaluate the value of contrast-enhanced ultrasound (CEUS) in the cesarean scar pregnancy (CSP). Methods. Clinical data from 92 patients with lower uterine segment pregnancy, who underwent conventional ultrasound and CEUS examination in the Department of Obstetrics and Gynecology, were collected by Xinqiao Hospital Third Military Medical University from March 2014 to March 2015. The parameters of ultrasound contrast time-intensity curve (TIC), including arrival time, time to peak, time from peak to one half, basic intensity, peak intensity, and wash-in slope, were analyzed. Results. Of the 92 cases of patients with pregnancy in the lower uterine segment, 52 cases were CSP, and 40 cases were intrauterine pregnancy. CEUS was significantly better than conventional ultrasound in terms of sensitivity, negative predictive value, Youden index, and diagnostic accuracy (P < 0.05). There was no significant difference in specificity and positive predictive value (P > 0.05). Conclusion. CEUS has a higher accuracy than conventional ultrasound in diagnosis of CSP.

Focal Lesions in Fatty Liver: If Quantitative Analysis Facilitates the Differentiation of Atypical Benign from Malignant Lesions

To evaluate the diagnostic performance of quantitative analysis as an adjunctive diagnostic tool to contrast-enhanced ultrasound (US) for the differentiation of atypical benign focal liver lesions (FLLs) from malignancies in fatty liver. Twenty-seven benign FLLs and fifty-six malignant FLLs that appeared hyper-enhanced during the arterial phase with washout in the portal or late phase in fatty liver were analyzed. Chi-square tests and logistic regression were applied to identify the specific features. Three sets of criteria were assigned: 1) all FLLs subjected to routine contrast-enhanced US; 2) all FLLs subjected to quantification analysis and contrast-enhanced US; and 3) parts of FLLs that could not be diagnosed using contrast-enhanced US (n = 66, 75.9%) but instead were diagnosed using parametric features. The sensitivity, specificity, accuracy and area under the receiver operating characteristic curve (AUC) of the three sets of criteria were analyzed. The AUCs of the criterion set 2 were significantly higher than those of criterion set 1 (0.904 versus 0.792, P = 0.008). Criterion set 3 showed a relatively high sensitivity (90.2%) with a relatively high AUC (0.845). The quantification analysis offers improved diagnostic performance for the differential identification of atypical benign FLLs from malignancies in fatty liver.

Preliminary results of contrast-enhanced sonography in the evaluation of the response of uveal melanoma to gamma-knife radiosurgery

PURPOSE

Our aim was to prospectively analyze the use of contrast-enhanced ultrasound (CEUS) in the quantitative assessment of the response of uveal melanoma (UM) to gamma-knife radiosurgery (GKR), investigating whether changes in tumor vascularization precede thickness reduction, which on average occurs at 12 months after GKR.

METHODS

Ten patients with UM treated with GKR underwent sonography (US) and CEUS at baseline and at 3, 6, and 12 months after GKR. The transverse diameter, thickness, and quantitative parameters of the UM (ie, area under the curve in the wash-in phase, wash-in perfusion index, peak enhancement, and wash-in rate) were calculated by using dedicated software and compared by using Wilcoxon's signed-rank test.

RESULTS

The mean tumor thickness on US was significantly less at both 6 (6.6 mm) and 12 months after GKR (5.8 mm) than it was at baseline (8.3 mm; p < 0.05, both comparisons). Compared with baseline data, the median flow quantitative parameters on CEUS were significantly changed as follows: the peak enhancement (in arbitrary units [au]) at baseline was 5 × 10(6) ; 6 months after GKR, it was 2 × 10(1) (p < 0.05), and 12 months after GKR, it was 4 × 10(1) (p < 0.05). The wash-in rate (in au) at baseline was 1 × 10(6) ; 6 months after GKR, it was 2.1 (p < 0.05), and 12 months after GKR, it was 9.3 (p < 0.05). The wash-in perfusion index (in au) at baseline was 2 × 10(7) ; 6 months after GKR, it was 7 × 10(1) (p < 0.05), and 12 months after GKR, it was 1 × 10(2) (p < 0.05). The area under the curve during the wash-in phase (in au) at baseline was 1 × 10(8) ; 12 months after GKR, it was reduced to 6 × 10(2) (p < 0.05).

CONCLUSIONS

At 6 months after GKR, a reduction of tumor thickness, as detected on US, occurred in 6 of the 10 patients, whereas a reduction in all the quantitative parameters measured on CEUS occurred in all 10 patients. However, a larger population is needed to investigate whether CEUS could become the first-choice technique for monitoring the response of UM to GKR.

Contrast-enhanced ultrasonography: advance and current status in abdominal imaging

In the field of contrast-enhanced ultrasonography (US), contrast agents are classified as either first- or second-generation agents depending on the gas within the microbubbles. In the case of first-generation contrast agents, a high-mechanical-index technique is used and only intermittent scanning is possible due to the early destruction of the microbubbles during the scanning. The use of second-generation contrast agents in a low-mechanical-index technique enables continuous scanning. Besides the detection and characterization of focal liver lesions, contrastenhanced US is helpful in the monitoring of radiofrequency ablation therapy and in the targeting step of an US-guided biopsy. Recently, there has been a demand for new criteria to evaluate the treatment response obtained using anti-angiogenic agents because morphologic criteria alone may not reflect the treatment response of the tumor and contrast-enhanced US can provide quantitative markers of tissue perfusion. In spite of the concerns related to its cost-effectiveness, contrast-enhanced US has the potential to be more widely used as a complimentary tool or to substitute the current imaging modalities in some occasions.

Correlation between maximum intensity and microvessel density for differentiation of malignant from benign thyroid nodules on contrast-enhanced sonography

OBJECTIVES

The purpose of this study was to retrospectively evaluate contrast-enhanced sonography for differentiation of benign and malignant thyroid nodules by analyzing the correlation between maximum intensity and microvessel density.

METHODS

From February 2010 to May 2012, 122 patients (85 female and 37 male; mean age ± SD, 45 ± 9.1 years) with thyroid nodules (62 papillary thyroid carcinomas, 30 nodular goiters, and 30 adenomas) that underwent routine thyroid sonography and were diagnosed by surgery were included in this study. Contrast-enhanced sonography was performed, and enhancement patterns were classified into 3 groups: high, equal, and low enhancement. As a time-intensity curve parameter, the correlation of maximum intensity with CD31 and CD34 microvessel density counts was analyzed.

RESULTS

On contrast-enhanced sonography, most patients with papillary thyroid carcinomas showed a heterogeneous low enhancement pattern, whereas most patients with nodular goiters showed an equal enhancement pattern, and patients with adenomas showed a high enhancement pattern. The detection of papillary thyroid carcinomas with low enhancement had sensitivity of 96.8%, specificity of 95.0%, and accuracy of 95.9%. Compared with the papillary thyroid group, the mean microvessel density counts were significantly higher in the nodular goiter and adenoma groups (P< .05). We also found that the maximum intensity was significantly associated with CD31 and CD34 counts (CD31, r = 0.963; P < .01; CD34, r = 0.968; P < .01).

CONCLUSIONS

Maximum intensity has a significant relationship with microvessel density. Contrast-enhanced sonography is a practical and convenient means for differentiating benign from malignant thyroid nodules.

The prognostic implications of microvascular density and lymphatic vessel density in esophageal squamous cell carcinoma: Comparative analysis between the traditional whole sections and the tissue microarray

Focal distribution of microvascular and lymphatic vessels is a critical issue in cancer, and is measured by tissue microarray (TMA) construction from paraffin-embedded surgically obtained tissues, a process that may not accurately reflect true focal distribution. The aim of this study was to assess the concordance of microvascular density (MVD) and lymphatic vessel density (LVD) in TMAs with corresponding whole sections, and to correlate the MVD or LVD with clinicopathological parameters in 124 cases of esophageal squamous cell carcinoma (ESCC). MVD, determined by CD105 immunohistochemistry of whole sections, was strongly associated with lymph node metastasis (p=0.000) and pTNM stage (p=0.001). Kaplan-Meier survival analysis showed that increasing CD105 microvessel count correlated with decreasing survival (p<0.001). The same result was acquired when MVD was calculated from tissue microarrays. Analysis of continuous data showed a highly significant correlation between whole sections and TMA data (Pearson r=0.522, p<0.001). Increasing LVD, as determined by D2-40 immunohistochemistry of whole sections, correlated with decreasing survival, but this relationship was undetectable using TMAs. In conclusion, we demonstrate that for the selected endothelial markers, TMAs can provide a realistic and reliable estimate of the extent of MVD, but not LVD in ESCC samples.

2D ultrasonography and contrast enhanced ultrasound for the evaluation of cavitating mesenteric lymph node syndrome in a patient with refractory celiac disease and enteropathy T cell lymphoma

Background

The cavitating mesenteric lymph node syndrome (CMLNS) is a rare manifestation of celiac disease, with an estimated mortality rate of 50%. Specific infections and malignant lymphoma may complicate its clinical course and contribute to its poor prognosis. Diagnosing the underlying cause of CMLNS can be challenging. This is the first report on contrast enhanced ultrasound (CEUS) findings in enteropathy associated T-cell lymphoma (EATL) complicating CMLNS in a gluten-free compliant patient with persistent symptoms and poor outcome.

Case presentation

We present the case of a 51-year old Caucasian male patient, diagnosed with celiac disease and CMLNS. Despite his compliance to the gluten-free diet the symptoms persisted and we eventually considered the possible development of malignancy. No mucosal changes suggestive of lymphoma were identified with capsule endoscopy. Low attenuation mesenteric lymphadenopathy, without enlarged small bowel segments were seen on computed tomography. CEUS revealed arterial rim enhancement around the necrotic mesenteric lymph nodes, without venous wash-out. No malignant cells were identified on laparoscopic mesenteric lymph nodes biopsies. The patient died due to fulminant liver failure 14 months later; the histopathological examination revealed CD3/CD30-positive atypical T-cell lymphocytes in the liver, mesenteric tissue, spleen, gastric wall, kidney, lung and bone marrow samples; no malignant cells were present in the small bowel samples.

Conclusions

CEUS findings in EATL complicating CMLNS include arterial rim enhancement of the mesenteric tissue around the cavitating lymph nodes, without venous wash-out. This vascular pattern is not suggestive for neoangiogenesis, as arteriovenous shunts from malignant tissues are responsible for rapid venous wash-out of the contrast agent. CEUS failed to provide a diagnosis in this case.

Quantitative analysis of contrast-enhanced ultrasonography: differentiating focal nodular hyperplasia from hepatocellular carcinoma

OBJECTIVE

To explore the potential of quantitative analysis of contrast-enhanced ultrasonography (CEUS) in differentiating focal nodular hyperplasia (FNH) from hepatocellular carcinoma (HCC).

METHODS

34 cases of FNH and 66 cases of HCC (all lesions <5 cm) were studied using CEUS to evaluate enhancement patterns and using analytic software Sonoliver® (Image-Arena™ v.4.0, TomTec Imaging Systems, Munich, Germany) to obtain quantitative features of CEUS in the region of interest. The quantitative features of maximum of intensity (IMAX), rise slope (RS), rise time (RT) and time to peak (TTP) were compared between the two groups and applied to further characterise both FNH and HCC with hypoenhancing patterns in the late phase on CEUS.

RESULTS

The sensitivity and specificity of CEUS for diagnosis of FNH were 67.6% and 93.9%, respectively. For quantitative analysis, IMAX and RS in FNHs were significantly higher than those in HCCs (p<0.05), while RT and TTP in FNHs were significantly shorter (p<0.05). Both the 11 FNHs and 62 HCCs with hypo-enhancing patterns in the late phase were further characterised with their quantitative features, and the sensitivity and specificity of IMAX for diagnosis of FNH were 90.9% and 43.5%, RS 81.8% and 80.6%, RT 90.9% and 71.0%, and TTP 90.9% and 71.0%, respectively.

CONCLUSION

The quantitative features of CEUS in FNH and HCC were significantly different, and they could further differentiate FNH from HCC following conventional CEUS.

ADVANCES IN KNOWLEDGE

Our findings suggest that quantitative analysis of CEUS can improve the accuracy of differentiating FNH from HCC.

Evaluation of tumor angiogenesis in a mouse PC-3 prostate cancer model using dynamic contrast-enhanced sonography

OBJECTIVES

The purpose of this study was to evaluate tumor angiogenesis in a mouse xenograft model injected with human PC-3 prostate cancer cells using contrast-enhanced sonography.

METHODS

Sixteen nude mice were injected with human prostate cancer cells on the back or the flank. Contrast-enhanced sonography was performed with a 5- to 12-MHz broadband linear transducer after a 500-μL bolus injection of a sonographic contrast agent composed of lipid shells and sulfur hexafluoride. Contrast-enhanced sonograms were obtained by the pulse inversion coded harmonic technique with a low mechanical index of 0.07. A region of interest was drawn to encompass the tumor, and time-intensity curves were acquired. After fitting the curve by a gamma variate function, the maximum intensity, area under the curve for up to 50 seconds, time to peak, shape parameter, and scale parameter were derived. The tumor volume, percentage of vascular endothelial growth factor expression, and CD31-positive vessel count (microvessel density) were correlated with the parameters derived from the time-intensity curve.

RESULTS

The maximum intensity was positively correlated with the microvessel density with statistical significance (r = 0.552; P = .03). The percentage of vascular endothelial growth factor expression did not have any correlation with the parameters from the curve.

CONCLUSIONS

Contrast-enhanced sonography can reflect tumor vascularity in a prostate cancer animal model. Sonography of tumor angiogenesis may permit functional assessment of the tumor vasculature and provide an imaging biomarker for tumor responses to antiangiogenic therapies.

Contrast-enhanced ultrasonography of hepatocellular carcinoma: correlation between quantitative parameters and histological grading

OBJECTIVE

The quantitative parameters in the contrast-enhanced ultrasonography time-intensity curve of hepatocellular carcinoma (HCC) were studied to explore their possible implication for histological grading of HCC.

METHODS

A total of 130 HCC patients (115 males and 15 females; age: 48.13±11.00 years) were studied using contrast-enhanced ultrasonography time-intensity curve and histological pathology. The quantification software Sonoliver® (TomTec Imaging Systems, Unterschleissheim, Germany) was applied to derive time-intensity curves of regions of interest in the interior of HCCs and in reference. Quantitative parameters of 115 patients were successfully obtained, including maximum of intensity (IMAX), rise time (RT), time to peak (TTP), rise slope (RS) and washout time (WT). Histological grading of HCC was performed using haematoxylin-eosin staining, and monoclonal antibodies specific for smooth muscle actin were used to observe unpaired arteries (UAs).

RESULTS

There were significant differences among WTs in the three differentiated HCC groups (p<0.05). However, there were no significant differences among RT, TTP, RS and IMAX in the differentiated HCC groups. Moreover, the number of UAs in the differentiated HCC groups showed no statistical significance.

CONCLUSION

WT plays an important role in predicting well, moderately and poorly differentiated HCC.