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Lim AKP, Satchithananda K, Dick EA, Abraham S, Cosgrove DO. Microflow imaging: New Doppler technology to detect low-grade inflammation in patients with arthritis. Eur Radiol 2017; 28:1046-1053. [PMID: 29022101 PMCID: PMC5811585 DOI: 10.1007/s00330-017-5016-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 06/04/2017] [Accepted: 08/02/2017] [Indexed: 11/28/2022]
Abstract
Aim To assess the efficacy of microvascular imaging in detecting low-grade inflammation in arthritis compared with Power Doppler ultrasound (PDUS). Method and materials Patients presenting for ultrasound with arthralgia were assessed with grey-scale, PDUS and Superb Microvascular Imaging (SMI). Videoclips were stored for analysis at a later date. Three musculoskeletal radiologists scored grey-scale changes, signal on PDUS and/or SMI within these joints. If a signal was detected on both PDUS and SMI, the readers graded the conspicuity of vascular signal from the two Doppler techniques using a visual analogue scale. Results Eighty-three patients were recruited with 134 small joints assessed. Eighty-nine of these demonstrated vascular flow with both PD and SMI, whilst in five no flow was detected. In 40 joints, vascularity was detected with SMI but not with PDUS (p = 0.007). Out of the 89 joints with vascularity on both SMI and PDUS, 23 were rated as being equal; while SMI scored moderately or markedly better in 45 cases (p <0.001). Conclusion SMI is a new Doppler technique that increases conspicuity of Doppler vascularity in symptomatic joints when compared to PDUS. This allows detection of low grade inflammation not visualised with Power Doppler in patients with arthritis. Key Points • SMI detects vascularity with improved resolution and sensitivity compared to Power Doppler. • SMI can detect low-grade inflammation not seen with Power Doppler. • Earlier detection of active inflammation could have significant impact on treatment paradigms. Electronic supplementary material The online version of this article (doi:10.1007/s00330-017-5016-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A K P Lim
- Department of Imaging, Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK. .,Department of Experimental Medicine and Therapeutics, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London, W12 0HS, UK. .,Digestive Diseases, Department of Surgery and Cancer, Imperial College London, QEQM, St. Mary's Hospital, Praed Street W2, London, UK.
| | - K Satchithananda
- Department of Imaging, Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK
| | - E A Dick
- Department of Imaging, Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK
| | - S Abraham
- Digestive Diseases, Department of Surgery and Cancer, Imperial College London, QEQM, St. Mary's Hospital, Praed Street W2, London, UK.,Department of Rheumatology and Medicine, NIHR/Wellcome Clinical Research Facility, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London, W12 OHS, UK
| | - D O Cosgrove
- Department of Imaging, Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK
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Lim AKP, Patel N, Eckersley RJ, Fitzpatrick J, Crossey MME, Hamilton G, Goldin RD, Thomas HC, Vennart W, Cosgrove DO, Taylor-Robinson SD. A comparison of 31P magnetic resonance spectroscopy and microbubble-enhanced ultrasound for characterizing hepatitis c-related liver disease. J Viral Hepat 2011; 18:e530-4. [PMID: 21914073 DOI: 10.1111/j.1365-2893.2011.01455.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
We compared in vivo hepatic (31) P magnetic resonance spectroscopy ((31) P MRS) and hepatic vein transit times (HVTT) using contrast-enhanced ultrasound with a microbubble agent to assess the severity of hepatitis C virus (HCV)-related liver disease. Forty-six patients with biopsy-proven HCV-related liver disease and nine healthy volunteers had (31) P MRS and HVTT performed on the same day. (31) P MR spectra were obtained at 1.5 T. Peak areas were calculated for metabolites, including phosphomonoesters (PME) and phosphodiesters (PDE). Patients also had the microbubble ultrasound contrast agent, Levovist (2 g), injected into an antecubital vein, and time-intensity Doppler ultrasound signals of the right and middle hepatic veins were measured. The HVTT was calculated as the time from injection to a sustained rise in Doppler signal 10% greater than baseline. The shortest times were used for analysis. Based on Ishak histological scoring, there were 15 patients with mild hepatitis, 20 with moderate/severe hepatitis and 11 with cirrhosis. With increasing severity of disease, the PME/PDE ratio was steadily elevated, while the HVTT showed a monotonic decrease. Both imaging modalities could separate patients with cirrhosis from the mild and moderate/severe hepatitis groups. No statistical difference was observed in the accuracy of each test to denote mild, moderate/severe hepatitis and cirrhosis (Fisher's exact test P =1.00). (31) P MRS and HVTT show much promise as noninvasive imaging tests for assessing the severity of chronic liver disease. Both are equally effective and highly sensitive in detecting cirrhosis.
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Affiliation(s)
- A K P Lim
- Imaging Sciences Department, Institute of Clinical Sciences Centre, Faculty of Medicine, London, UK.
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Tang MX, Mulvana H, Gauthier T, Lim AKP, Cosgrove DO, Eckersley RJ, Stride E. Quantitative contrast-enhanced ultrasound imaging: a review of sources of variability. Interface Focus 2011; 1:520-39. [PMID: 22866229 PMCID: PMC3262271 DOI: 10.1098/rsfs.2011.0026] [Citation(s) in RCA: 184] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Accepted: 04/26/2011] [Indexed: 12/14/2022] Open
Abstract
Ultrasound provides a valuable tool for medical diagnosis offering real-time imaging with excellent spatial resolution and low cost. The advent of microbubble contrast agents has provided the additional ability to obtain essential quantitative information relating to tissue vascularity, tissue perfusion and even endothelial wall function. This technique has shown great promise for diagnosis and monitoring in a wide range of clinical conditions such as cardiovascular diseases and cancer, with considerable potential benefits in terms of patient care. A key challenge of this technique, however, is the existence of significant variations in the imaging results, and the lack of understanding regarding their origin. The aim of this paper is to review the potential sources of variability in the quantification of tissue perfusion based on microbubble contrast-enhanced ultrasound images. These are divided into the following three categories: (i) factors relating to the scanner setting, which include transmission power, transmission focal depth, dynamic range, signal gain and transmission frequency, (ii) factors relating to the patient, which include body physical differences, physiological interaction of body with bubbles, propagation and attenuation through tissue, and tissue motion, and (iii) factors relating to the microbubbles, which include the type of bubbles and their stability, preparation and injection and dosage. It has been shown that the factors in all the three categories can significantly affect the imaging results and contribute to the variations observed. How these factors influence quantitative imaging is explained and possible methods for reducing such variations are discussed.
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Affiliation(s)
- M.-X. Tang
- Department of Bioengineering, Imperial College London, London SW7 2AZ, UK
| | - H. Mulvana
- Imaging Sciences Department, Faculty of Medicine, Imperial College London, London W12 0HS, UK
| | - T. Gauthier
- Department of Experimental Medicine and Toxicology, Hammersmith Hospital, Imperial College London, London W12 0NN, UK
| | - A. K. P. Lim
- Hammersmith Hospital, MRC Clinical Sciences Centre, Faculty of Medicine, Imperial College London, London W12 0NN, UK
| | - D. O. Cosgrove
- Imaging Sciences Department, Faculty of Medicine, Imperial College London, London W12 0HS, UK
| | - R. J. Eckersley
- Imaging Sciences Department, Faculty of Medicine, Imperial College London, London W12 0HS, UK
| | - E. Stride
- Department Mechanical Engineering, University College London, London WC1E 7JE, UK
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Lim AKP, Patel N, Eckersley RJ, Cobbold JFL, Crossey MME, Cosgrove DO, Goldin RD, Thomas HC, Taylor-Robinson SD. Hepatic vein transit times of a microbubble agent in assessing response to antiviral treatment in patients with chronic hepatitis C. J Viral Hepat 2010; 17:778-83. [PMID: 20002308 DOI: 10.1111/j.1365-2893.2009.01234.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Microbubble measurement of hepatic vein transit times (HVTT) may have the potential to assess severity of hepatitis C virus (HCV)-related liver disease, where there is a shorter HVTT with more severe disease. We investigated the utility of this test as a marker of response to antiviral treatment. Thirty-seven patients with biopsy-proven HCV-related disease undergoing antiviral treatment were studied. All had baseline scans and then repeat scans 6 months after the end of treatment. HVTT using Levovist were obtained from the right and middle hepatic veins, and the shorter time was used for analysis. The aspartate aminotransferase to platelet ratio index (APRI) scores were calculated retrospectively. There were seven patients with mild hepatitis, 23 with moderate/severe hepatitis and seven with cirrhosis. The mean baseline HVTT in responders ± SE increased from 27.3 ± 2.29 s to 33.5 ± 2.8 s posttreatment (P = 0.01). In the 10 nonresponders, the HVTT remained the same; 43.3 ± 9 s baseline compared to 44 ± 7.8 s posttreatment (P = 0.84). This trend was also seen with the APRI score where in responders, the mean score decreased from 1.1 ± 0.2 to 0.74 ± 1 (P = 0.03) and in nonresponders, the score remained unchanged; 0.88 ± 0.2 compared to 0.84 ± 0.2 (P = 0.31). HVTT measurement lengthened, while APRI scores decreased in patients who responded to antiviral treatment while both remained the same, shortened (HVTT) or increased (APRI), respectively, in patients who were nonresponders. These results are encouraging and indicate that these tests could be potentially used as markers of response to treatment and could obviate the need for serial biopsies in antiviral future treatment studies.
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Affiliation(s)
- A K P Lim
- Clinical Sciences Centre, Faculty of Medicine, Imperial College London, Hammersmith Hospital, London, UK.
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Sorelli PG, Cosgrove DO, Svensson WE, Zaman N, Satchithananda K, Barrett NK, Lim AKP. Can contrast-enhanced sonography distinguish benign from malignant breast masses? J Clin Ultrasound 2010; 38:177-181. [PMID: 20146214 DOI: 10.1002/jcu.20671] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND We investigated whether microvascular enhancement on contrast-enhanced sonographic (CEUS) imaging can aid in distinguishing between benign and malignant lesions and correlated these findings with histopathological findings. METHOD Fifteen patients with a palpable breast mass were recruited. Following informed consent, 4.8 mL of the microbubble contrast agent SonoVue was injected intravenously. Digital video clips of lesion enhancement were obtained and reviewed by a consultant radiologist who scored each lesion on the following characteristics: homogeneous versus heterogeneous enhancement, the presence or absence of focal defects, well- versus ill-defined margins and vascular morphology score (VMS). RESULT Histologically there were 7 malignant and 8 benign lesions. The calculated sensitivity for CEUS in the diagnosis of malignancy was 100%, with a 37.5% specificity. There was no statistically significant difference in overall mean VMS between the malignant and benign lesions. CONCLUSION The results of our study have not shown any additional benefit in the use of CEUS over conventional triple assessment. The positive trend seen in the higher mean VMS for the malignant tumors needs further investigation with a larger cohort of patients.
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Affiliation(s)
- P G Sorelli
- Department of Surgery, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, United Kingdom
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Wakeham NR, Satchithananda K, Svensson WE, Barrett NK, Comitis S, Zaman N, Ralleigh G, Sinnett D, Shousha S, Lim AKP. Colorectal breast metastases presenting with atypical imaging features. Br J Radiol 2008; 81:e149-53. [PMID: 18440938 DOI: 10.1259/bjr/62391254] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Breast metastases from non-breast primaries are rare in female patients and exceedingly rare in male patients, with only a handful of cases described. Lymphoma, metastatic melanoma and bronchial carcinoma are the primary sites for the majority of breast metastases. Breast metastases from colorectal carcinoma have been described previously in only a small number of cases in the literature. Here, we report a further two patients with biopsy-proven colorectal carcinoma metastases to both breasts, who demonstrate contrasting unusual and atypical imaging features that have not been reported previously. In one case, the imaging appearances mimic a multifocal primary breast carcinoma. Metastatic disease in the breast is a marker for disseminated metastatic spread, with a correspondingly poor prognosis. Therefore, we review the imaging features that differentiate metastatic breast disease from multifocal breast primaries, which are important to recognize because the management options for these patients differ greatly.
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Affiliation(s)
- N R Wakeham
- Department of Radiology, West of London Breast Screening Service, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK.
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Lim AKP, Taylor-Robinson SD, Patel N, Eckersley RJ, Goldin RD, Hamilton G, Foster GR, Thomas HC, Cosgrove DO, Blomley MJK. Hepatic vein transit times using a microbubble agent can predict disease severity non-invasively in patients with hepatitis C. Gut 2005; 54:128-33. [PMID: 15591518 PMCID: PMC1774345 DOI: 10.1136/gut.2003.030965] [Citation(s) in RCA: 120] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS A reliable non-invasive assessment of the severity of diffuse liver disease is much needed. We investigated the utility of hepatic vein transit times (HVTT) for grading and staging diffuse liver disease in a cohort of patients with hepatitis C virus (HCV) infection using an ultrasound microbubble contrast agent as a tracer. MATERIALS AND METHODS Eighty five untreated patients with biopsy proven HCV induced liver disease were studied prospectively. All were HCV RNA positive on polymerase chain reaction testing. Based on their histological fibrosis (F) and necroinflammatory (NI) scores, untreated patients were divided into mild hepatitis (F < or =2/6, NI < or =3/18), moderate/severe hepatitis (3 < or =F <6 or NI > or =4), and cirrhosis (F=6/6) groups. In addition, 20 age matched healthy volunteers were studied. After an overnight fast, a bolus of contrast agent (Levovist) was injected into an antecubital vein and spectral Doppler signals were recorded from both the right and middle hepatic veins for analysis. HVTTs were calculated as the time from injection to a sustained rise in Doppler signal >10% above baseline. The Doppler signals from the carotid artery were also measured in 60 patients and carotid delay times (CDT) calculated as the difference between carotid and hepatic vein arrival times. The earliest HVTT in each patient was used for analysis. RESULTS Mean (SEM) HVTT for the control, mild hepatitis, moderate/severe hepatitis, and cirrhosis groups showed a monotonic decrease of 38.1 (2.8), 38.8 (2.4), 26.0 (2.4), and 15.8 (0.8) seconds, respectively. Mean (SEM) CDT for the control, mild hepatitis, moderate/severe hepatitis, and cirrhosis patients again showed progressive shortening of 30.3 (2.6), 25.9 (2.6), 14.8 (2.1), and 5.6 (1.2) seconds, respectively. There were significant differences between the groups for HVTT (ANOVA, p<0.001) and CDT (ANOVA, p<0.001). There was 100% sensitivity and 80% specificity for diagnosing cirrhosis and 95% sensitivity and 86% specificity for differentiating mild hepatitis from more severe liver disease. CONCLUSION We have shown, for the first time, that HVTT using an ultrasound microbubble contrast agent can assess HCV related liver disease with clear differentiation between mild hepatitis and cirrhosis. There were significant differences between these two groups and the moderate/severe hepatitis group. CDT offers no additional benefit or greater differentiation than HVTT and can be omitted, thus simplifying this technique. HVTT may complement liver biopsy and may also be a useful alternative for assessment of liver disease in patients who have contraindications to biopsy.
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Affiliation(s)
- A K P Lim
- Imaging Sciences Department, MRC Clinical Services Centre, Faculty of Medicine, Imperial College, The Robert Steiner MR Unit, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK.
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Blomley MJK, Lim AKP, Harvey CJ, Patel N, Eckersley RJ, Basilico R, Heckemann R, Urbank A, Cosgrove DO, Taylor-Robinson SD. Liver microbubble transit time compared with histology and Child-Pugh score in diffuse liver disease: a cross sectional study. Gut 2003; 52:1188-93. [PMID: 12865280 PMCID: PMC1773750 DOI: 10.1136/gut.52.8.1188] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND A previous pilot study showed that early arrival time of a microbubble in a hepatic vein is a sensitive indicator of cirrhosis. AIM To see if this index can also grade diffuse liver disease. PATIENTS Thirty nine fasted patients with histologically characterised disease were studied prospectively. Nine patients had no evidence of liver fibrosis, 10 had fibrosis without cirrhosis, and 20 had cirrhosis (five Child's A, seven Child's B, and eight Child's C). METHODS Bolus injections of a microbubble (Levovist; Schering, Berlin) were given intravenously, followed by a saline flush. Time intensity curves of hepatic vein and carotid artery spectral Doppler signals were analysed. Hepatic vein transit time (HVTT) was calculated as the time after injection at which a sustained signal increase >10% of baseline was seen. Carotid delay time (CDT) was calculated as the difference between carotid and hepatic vein enhancement. RESULTS Diagnostic studies were achieved in 38/39 subjects. Both HVTT and CDT became consistently shorter with worsening disease, as follows (means (SD)): HVTT: no fibrosis 44 (25) s, fibrosis 26 (8) s, Child's A 21 (1) s, Child's B 16 (3) s, and Child's C 16 (2) s; CDT: no fibrosis 31 (29) s, fibrosis 14 (6) s, Child's A 8 (1) s, Child's B 4 (4) s, and Child's C 3 (3) s. These differences were highly significant (p<0.001, ANOVA comparison). A HVTT <24 s and a CDT <10 s were 100% sensitive for cirrhosis (20/20 and 18/18, respectively) but not completely specific: 2/8 subjects with fibrosis had CDT values <10 s and 3/9 had HVTT <24 s. CONCLUSION This minimally invasive test shows promise not only in diagnosing cirrhosis but also in assessing disease severity.
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Affiliation(s)
- M J K Blomley
- Imaging Sciences Department, Clinical Sciences Division, Faculty of Medicine, Imperial College, Hammersmith Hospital Campus, Du Cane Rd, London, UK.
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Lim AKP, Patel N, Gedroyc WMW, Blomley MJK, Hamilton G, Taylor-Robinson SD. Hepatocellular adenoma: diagnostic difficulties and novel imaging techniques. Br J Radiol 2002; 75:695-9. [PMID: 12153946 DOI: 10.1259/bjr.75.896.750695] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We report the case of a 30-year-old eastern European female who presented with right upper quadrant pain. Clinical examination was unremarkable and liver function tests were normal. CT identified a 5 cm lesion in segment V of the liver, which was of homogeneous low density with no calcification or significant enhancement. MRI showed the lesion to be hypointense to liver on T(1) weighted sequences and isointense on T(2) weighted sequences. Rapid arterial enhancement with gadolinium-DTPA faded without leaving a definite central scar. Ultrasound showed the lesion to be echogenic with minimal vascularity. Administration of a liver-specific microbubble contrast agent showed low uptake relative to the surrounding liver. Phosphorus-31 MR spectroscopy, localized to the lesion itself, revealed a markedly increased phosphomonoester resonance with a decreased phosphodiester resonance, compatible with increased cell turnover. Biopsy confirmed the lesion to be a hepatocellular adenoma. The diagnosis of a hepatic adenoma is difficult with tissue diagnosis the gold standard, but it may be suggested by a combination of imaging modalities. We have described two new imaging techniques not previously described in characterization of hepatic adenomata, namely ultrasound with contrast agent and MR spectroscopy.
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Affiliation(s)
- A K P Lim
- Robert Steiner MRI Unit, MRC Clinical Sciences Centre, Imperial College School of Medicine, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
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