Diagnostic Performance of Superb Microvascular Imaging in Differentiating Benign and Malignant Axillary Lymph Nodes

ABSTRACT

The aim was to evaluate the effectiveness of superb microvascular imaging (SMI) in axillary lymph nodes (LNs).Benign and malignant LNs diagnosed via histopathological examination constituted the study subgroups. In addition to grayscale findings for morphological evaluation, vascular patterns and appearance of internal vessels were analyzed by both power Doppler ultrasound (PDUS) and SMI. The number of vascular branches was counted, and a vascularity index (VI) was calculated by SMI.Fifty-two LNs with suspicious findings in terms of metastasis (33 malignant and 19 benign) were evaluated. Diagnostic accuracy according to vascular patterns was 82% for PDUS and 92% for SMI. In the presence of asymmetric cortical thickening, there was a significant difference between benign and malignant LNs in the number of vascular branches of both thin and thick cortical sides ( P < 0.01). Mean VI was significantly higher in the malignant group ( P < 0.05). In differentiating malignancy, when a cutoff VI value was set to 9%, sensitivity was 69.7%, and specificity was 63.2%.Evaluating the vascularity of axillary LNs by SMI is a useful tool in determining the potential of axillary metastasis, especially in the absence of typical sonographic findings. Superb microvascular imaging can beneficially be used to select the most suspicious LN and suspicious area of the LN to sample.

Is there a potential biomarker in distinguishing invasive breast carcinomas with elevated Ki-67 levels among 2D-SWE, SMI, and 18F-FDG PET-CT/MRI-derived parameters?: A single-center data

PURPOSE

To investigate the strength of quantitative imaging and metabolic parameters in differentiating invasive breast carcinomas with elevated Ki-67 levels.

MATERIALS AND METHODS

A total of 123 patients with 129 breast lesions confirmed as invasive breast carcinoma underwent shear wave elastography (SWE), superb microvascular imaging (SMI) and positron emission tomography (PET)/CT or MRI. Adler's grade (classifying the microvascularity into four types) and Vascular Index (VI) was obtained by SMI as microvascular parameters. In addition, the stiffness value (E_mean ) was evaluated in kilopascal by SWE. The average of consecutive measurements was recorded as mean VI and mean E_mean . PET scan parameters were obtained as SUV_max and SUL_peak . Lesions were divided into two groups according to the Ki-67 expression, low as ≤ 14 and high as >14.

RESULTS

Adler's grading was the most correlated imaging parameter with high Ki-67 expression (p < 0.05), while VI and E_mean had poor correlation (p > 0.05). SUV_max and SUL_peak indicated a significant linear correlation with Ki-67 but a moderate correlation with the high levels of Ki-67 (p < 0,001). The sensitivity of VI, E_mean , SUV_max and SUL_peak was 64.6%, 66.7%, 65.7%, and 66.7% when the cut-off point was set to 5.25, 102.5, 6.59, and 2.63, respectively. SUV_max had the highest AUC value of 0.740, according to the ROC curve analysis.

CONCLUSIONS

Our results suggest that the quantitative parameters obtained by advanced imaging methods may be useful in predicting the high proliferation in invasive breast carcinomas. But none of them is eligible to be used as an independent biomarker in distinguishing aggressive behavior. Nevertheless, as a noninvasive method, visual assessment of microvascular morphology using SMI increases the prognostic efficiency in invasive breast carcinomas.

The Diagnostic Value of Superb Microvascular Imaging in Prediction of Uterine Artery Embolization Treatment Response in Uterine Leiomyomas

OBJECTIVES

We aimed to determine if superb microvascular imaging (SMI) can predict response to uterine artery embolization (UAE) as compared with power Doppler ultrasound.

METHODS

The blood flow and the volume of the dominant leiomyoma was evaluated by power Doppler ultrasonography (PDUS) and SMI 1 day before and 3 months after the UAE procedure. SMI and PDUS blood flow were classified to 4 grades of vascularity. The change in fibroid volume in Grades 0-2 (hypovascular group) was compared to the hypervascular Grade 3 group.

RESULTS

Twenty-eight women (mean age, 40.9 years; range, 33-53 years) were examined with PDUS and SMI before and 3 months after UAE. The volume reduction was statistically significantly higher hypervascular group (P < .05). When we accept 30% or more volume reduction as a good response to UAE, the positive predictive value, negative predictive value, sensitivity, specificity, and accuracy of SMI were 100, 64, 73.6, 100, and 82.1%, respectively. There was excellent agreement between the two blinded observers in SMI measurements.

CONCLUSIONS

SMI, with its high reproducibility, provides further microvessel information than PDUS in uterine fibroids. It may be a useful tool in prediction of response to UAE treatment and improve counseling and patient selection for UAE versus medical or surgical treatment options.

CT visual quantitative evaluation of hypertensive patients with coronavirus disease (COVID-19): Potential influence of angiotensin converting enzyme inhibitors / angiotensin receptor blockers on severity of lung involvement

OBJECTIVE

There is not enough data on the effect of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) on lung involvement in patients with COVID-19 pneumonia and hypertension (HT). Our aim was to compare the lung involvement of the HT patients hospitalized for COVID-19 using ACEIs/ARBs with the patients taking other anti-HT medications.

METHODS

: Patients who have a diagnosis of HT among the patients treated for laboratory-confirmed COVID-19 between 31 March 2020 and 28 May 2020 were included in the study. One hundred and twenty-four patients were divided into two as ACEIs/ARBs group (n = 75) and non-ACEIs/ARBs group (n = 49) according to the anti-HT drug used. The chest CT involvement areas of these two groups were evaluated quantitatively by two observers including all lobes, and total severity score (TSS) was calculated. These TSS values were compared between drug groups and clinical groups.

RESULTS

In clinical classification; there were 4 (%3.2) asymptomatic, 5 (4.0%) mild type, 92 (74.1%) common type, 14 (11.3%) severe type, 9 (7.3%) critical type patients. ACEI/ARB group's TSS (mean±SD, 7.74 ± 3.54) was statistically higher than other anti-HT medication group (mean±SD, 4.40 ± 1.89) (p < .001). Likewise, severe-critical clinical type's TSS (mean±SD, 9.17 ± 3.44) was statistically higher than common type (mean±SD, 5.76 ± 3.07) (p < .001). Excellent agreement was established between the two blinded observers in the TSS measurements.

CONCLUSIONS

Quantitative evaluation of CT and TSS score can give an idea about the clinical classification of the patient. TSS is higher in ACEI/ARB group than non-ACEIs/ARBs group.

Use of volumetric CT scanning to predict tumor staging and survival in pancreatic cancer patients that are to be administered curative resection

BACKGROUND

This study evaluates the achievability of CT volumetry of pancreatic cancer and its correlation with pTNM stage and survival.

METHODS

Tumor volume was measured from contrast enhanced CT images of 58 patients who undergo curative resection for pancreatic cancer using the Segment Editor module implemented in 3D-Slicer-a free open source software platform. Receiver operating characteristic (ROC) analysis was used to evaluate correlation between Tvol and pTNM staging.

RESULTS

The preoperative images of 58 pancreatic adenocarcinoma patients were included. The mean Tvol of pancreatic cancer is an increasing trend with T stage (The mean T1vol = 1.75 cm³ , the mean T2vol = 11.43 cm³ , the mean T3vol = 14.98 cm³ , the mean T4vol = 19.6 cm³ ). There were statistical differences between volumes (p = .000). On ROC analysis, the area under the ROC curve (Az) of Tvol to differentiate T1 stage from ≥T2 stage was 0.966 (p = .000). At a cut-off value of 3.050 cm³ , sensitivity of 92.3%, and specificity of 83.3% were achieved. Az value of Tvol to differentiate ≤T2 from ≥T3 stage was 0.750 (p = .010). At a cut-off value of 10.250 cm³ , sensitivity of 72.7% and specificity of 66% were achieved. In addition Az value of Tvol to differentiate ≤T3 from ≥T4 stage was 0.652 and was not significant (p = .380). At a cut-off value of 11.2 cm³ , sensitivity of 66.7% and specificity of 63.6% were achieved.

CONCLUSION

CT volumetry in pancreatic cancer is feasible with excellent reproducibility. It is one of the prognostic factors affecting survival in operated patients with pancreatic cancer.

The Role of Diffusion-weighted Imaging in Patients with Gastric Wall Thickening

BACKGROUND

Gastric cancer is the second leading cause of cancer death worldwide.

AIMS

In the benign and malign gastric pathologies, we measured the Apparent Diffusion Coefficient (ADC) value from the thickened section of the stomach wall. We assessed the diagnostic value of ADC and we wanted to see whether this value could be used to diagnose gastric pathologies.

STUDY DESIGN

This study has a prospective study design.

METHODS

A total of 90 patients, 27 with malign gastric pathologies 63 with benign gastric pathologies with Gastric Wall (GW) thickening in multidector CT, were evaluated by T2 weighted axial MR imaging and Diffusion-Weighted Imaging (DWI). Measurements were made both from the thickened wall and from the normal GW. Also, a new method called GW/spine ADC ratio was performed in image analysis. The value found after ADC measurement from the GW was proportioned to the spinal cord ADC value in the same section.

RESULTS

The ADC values measured from the pathological wall in patients with gastric malignancy (1.115 ± 0.156 x10-3 mm2/s) were significantly lower than the healthy wall measurements (1.621 ± 0.292 × 10-3 mm2/s) and benign gastric diseases (1.790± 0.359 x10-3 mm2/s). GW/spine ADC ratio was also lower in gastric malignancy group.

CONCLUSION

ADC measurement in DWI can be used to distinguish between benign and malign gastric pathologies.

Does measurement of the jugular foramen diameter on MRI help to differentiate transverse sinus thrombosis from unilateral transverse sinus hypoplasia?

BACKGROUND AND PURPOSE

The transverse sinus (TS) is a frequent location of cerebral venous thrombosis. However, unilateral TS hypoplasia is a frequent variation and radiological imaging pitfall in the diagnosis because it may mimic unilateral TS thrombosis. The purpose of this study is to find a cutoff value for bilateral jugular foramen (JF) diameter ratios on magnetic resonance imaging (MRI) for differentiating TS thrombosis from TS hypoplasia.

MATERIALS AND METHODS

We retrospectively reviewed magnetic resonance venography results for 174 patients with reduced unilateral TS caliber resulting from either unilateral thrombosis (80 patients) or unilateral hypoplasia (94 patients). We calculated the ratio by proportioning the diameter of the JF ipsilateral to the TS with caliber reduction to the diameter of the contralateral JF. The Mann-Whitney U test was used to compare the ratios between thrombosis and hypoplasia groups, and the cutoff value was calculated by receiver-operating characteristic curve analysis.

RESULTS

The ratio of bilateral JF diameters was lower in patients with hypoplasia than those with thrombosis (P < .01). The cutoff value to determine the diagnosis of TS hypoplasia with maximum accuracy was 0.638, with a sensitivity of 91.3% and specificity of 64.9%.

CONCLUSION

In equivocal cases, calculating the cutoff value by proportioning the diameter of JF ipsilateral to the TS with caliber reduction to the contralateral JF seems to be an efficient, quick, and straightforward method and valuable aid to differentiate TS thrombosis from TS hypoplasia.

Shearwave elastographic evaluation of uterine leiomyomas after uterine artery embolization: preliminary results

Background/aim

We aimed to investigate the role of Shearwave Elastography (SWE) in the evaluation of response to uterine artery embolization (UAE) in patients with uterine leiomyomas.

Materials and methods

SWE images of the dominant uterin leiomyomas were obtained before and 1.5 months after performing UAE in 33 women suffering from symptoms due to leiomyomas (menometrorrhagia, bulk related symptoms, pelvic pain). Leiomyomas were also evaluated by 2 observers for location and longest diameter in axial plane. Interobserver agreement in the quantitative SWE analysis was calculated using intraclass correlation coefficients.

Results

Thirty-three women (mean age, 39.7 years; range, 31–48 years) were examined with SWE 1.5 months after UAE. After treatment, 3 patients (9.1%) had fever, 1 patient had nausea and 29 patients (87.9%) had no complications. The post UAE stiffness measurements of leiomyomas (mean SWE ± SD = 13.34 ± 3.9kPa) were significantly lower than the pre UAE measurements (mean SWE ± SD = 17.16 ± 4.8kPa) (P < 0.001). There was excellent agreement between the 2 blinded observers in SWE measurements.

Conclusion

SWE values of leiomyomas after UAE significantly decreased. SWE, with its high reproducibility, could become a useful tool in the follow up of uterin leiomyomas after UAE.

The Relationship between Ocular Vascular Changes and the Levels of Malondialdehyde and Vascular Endothelial Growth Factor in Patients with Inflammatory Bowel Disease

Background: We evaluated ocular hemodynamic changes, malondialdehyde(MDA) and vascular endothelial growth factor (VEGF) levels in patients with IBD.Methods: We used ocular color Doppler ultrasonography to analyze 56 eyes with Crohn's disease (CD), 62 eyes with ulcerative colitis (UC), 68 eyes of healthy volunteers. We measured peak systolic velocity (PSV),end-diastolic velocity (EDV),and the resistivity index (RI) of ophthalmic artery (OA) and central retinal artery (CRA). MDA and VEGF levels were measured in the plasma samples.Results: MDA levels were significantly higher in both UC and CD patients, whereas VEGF levels were only higher in the CD group (p = .003,p < .001,p = .01).The PSV and EDV of the OA were significantly lower in CD patients (p = .017,p = .001). The EDV of the CRA was significantly lower in CD patients than UC patients and controls (p = .014,p < .001).Conclusions: CD patients exhibited decreased blood flow in both the OA and CRA. Ocular vascular flow was only affected in CD patients. We found that ocular ischemia may occur in CD patients even in the absence of any clinical finding.

Diagnostic Capabilities of MRI Versus 18F FDG PET-CT in Postoperative Patients with Thyroglobulin Positive, 131I-negative Local Recurrent or Metastatic Thyroid Cancer

BACKGROUND

The detection of recurrence or metastasis might be challenging in patients, who underwent total thyroidectomy and radioactive iodine therapy for Differentiated Thyroid Carcinoma (DTC), with increased serum Thyroglobulin (Tg) levels and negative 131I whole body scan (131I-WBS) results.

AIMS

The purpose of this study was to compare the ability of Magnetic Resonance Imaging (MRI) and 18F-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (18F FDG PET-CT) to detect recurrence or cervical and upper mediastinal metastases in postoperative DTC patients who had negative 131I-WBS despite elevated serum Tg levels.

STUDY DESIGN

This study has a retrospective study design.

METHODS

We evaluated cervical and upper mediastinal MRI and 18F FDG PET-CT of 32 postoperative patients with DTC (26 patients with papillary thyroid carcinoma and 6 patients with follicular thyroid carcinoma).

RESULTS

We evaluated 44 lesions in 32 patients. For all lesions, the Positive Predictive Value, (PPV) Negative Predictive Value (NPV), sensitivity, specificity, and accuracy of MRI were 81.4%, 76.4%, 84.6%, 72.2%, and 79.5% respectively. The PPV, NPV, sensitivity, specificity, and accuracy of 18F FDG PET-CT were 100.0%, 85.7%, 88.4%, 100.0%, and 93.1%, respectively.

CONCLUSION

Although we could not replace 18F FDG PET-CT, MRI might be used as an adjunct to 18F FDG PET-CT for the evaluation of recurrent or cervical and upper mediastinal metastatic thyroid cancers; however, MRI is inadequate for the detection of metastases in small lymph nodes.

Videofluoroscopic and Manometric Evaluation of Oropharyngeal and Esophageal Motility Disorders

BACKGROUND

Esophageal motility studies are performed in patients who have dysphagia that is not explained by stenosis. Diagnosis can be challenging and requires expertise in the interpretation of tests and symptoms.

AIMS

Our aim is to investigate the diagnostic value of videofluoroscopic swallowing study (VFSS) in combination with esophageal manometry.

STUDY DESIGN

This study has a prospective study design.

METHODS

73 patients with dysphagia underwent videofluoroscopy in a standing position. Each subject swallowed barium boluses and findings were correlated with manometry findings.

RESULTS

The study cohort was categorized into five groups according to their disease as achalasia (31.1%), presbyesophagus (4.1%), scleroderma (5.5%), neurogenic dysphagia (6.8%), and other diseases (54.4%), which included gastroesophageal reflux, diffuse esophageal spasm, cricopharyngeal achalasia, and diseases with nonspecific VFSS patterns. When evaluating VFSS, the perfect agreement was observed between two observers in the final diagnosis. (kappa: 0.91, p<0,001).

CONCLUSION

Although it does not replace manometry, VFSS is important as an additional useful imaging method in EMDs.

Double-Lumen Balloons, Are They Only Useful in Neurointerventions? Preliminary Outcomes of Double-Lumen Balloon-Assisted Embolization of Visceral Artery Aneurysms

Objectives:

This study aimed to assess the feasibility and results of double-lumen balloon-assisted embolization of visceral artery aneurysms (VAAs).

Methods:

Nine patients (mean age, 55.3 ± 10.8 years) diagnosed with VAA (superior mesenteric, n = 5; splenic, n = 2; renal, n = 2) and undergoing double-lumen balloon-assisted embolization were included in this study. Magnetic resonance angiogram (MRA) was used in the 6-month follow-up to assess the aneurysms and patency of the parent arteries.

Results:

All patients were successfully treated with no reports of morbidity or mortality. Residual filling of the aneurysm neck was detected in 2 patients at the end of the procedure, but those parts were found to be stable in the sixth-month MRA. In 1 patient with renal aneurysm, a stent had to be deployed using a double-lumen balloon catheter because of the prolapse of the coil into the main artery. In another patient with a very large-necked superior mesenteric artery aneurysm, additional coils could be used at the same time thanks to the double-lumen balloon as the coils were not stabilized enough during embolization with the microcatheter coils. Liquid embolic agent was also used in this patient from the same lumen because of the large diameter of the aneurysm.

Conclusions:

Double-lumen balloons, which are mostly used in neurointerventional procedures, can be efficiently used as in the treatment of VAAs due to their ability to deploy stent and perform coil-liquid embolization through 1 lumen.

Is there any relationship between carotid bifurcation geometry and hemodynamic depression after carotid stenting and angioplasty?

BACKGROUND

Hemodynamic depression (HD) is a condition that can be encountered after carotid stenting (CAS) and carotid angioplasty (CAP) due to manipulation of the carotid sinus. The aim of this study was to evaluate whether the carotid bifurcation geometry and angles, or changes in angles, were associated with this HD in patients undergoing CAS and CAP.

METHODS

Sixty-two patients with a mean age of 71.1±7.4 years, who underwent CAS and CAP for carotid stenosis were included in the study. HD was defined as periprocedural hypotension (systolic blood pressure <90 mmHg) or bradycardia (heart rate <60 bpm). The effect of carotid bifurcation geometry, plaque morphology and risk factors on subsequent development of HD was analyzed with binary logistic regression models. ICA-CCA angle was measured from digital subtraction angiographies (DSA) before and after stent deployment by two radiologists. Interobserver agreement was calculated.

RESULTS

Periprocedural HD was seen in 22 (35.5%) patients. Extension of carotid lesion to bulbus, preoperative internal carotid artery (ICA) angle, postoperative angular changes, pre-op systolic blood pressure, balloon-to-artery ratio and HD were significantly correlated. A significant difference was observed between the angle of ICA before and after the procedure between the patients with HD and those without HD.

CONCLUSIONS

Carotid anatomy and geometry may enhance the risk of HD independent of other factors and may be of help in very early identification of patients at high risk of developing HD after CAS and CAP.

Is there any association between jugular venous reflux and nonpulsatile subjective tinnitus? A preliminary study of four-dimensional magnetic resonance angiography

Objective

To demonstrate whether there is an association between jugular venous reflux and nonpulsatile subjective tinnitus (NST) using real-time four-dimensional magnetic resonance imaging (MRI) angiography.

Materials and Methods

Patients with unilateral NST who underwent contrast-enhanced MRI with a special protocol were included in the study. Thick slab dynamic maximum intensity projection images were obtained including interleaved stochastic trajectories (TWIST)-MRI examination. All patients were requested to perform Valsalva maneuver during the sequence. Jugular venous reflux grading was performed as follows: absence of reflux or if reflux does not reach the base of the skull: grade 0; if reflux reaches the jugular bulb, but no intracranial contrast is observed: grade 1; and if reflux extends into the intracranial cortical veins and/or the cavernous sinus above the jugular bulb: Grade 2.

Results

A total number of 30 patients, 23 male and 7 female, were included in the study. Jugular venous reflux was not identified (Grade 0) in 20 patients. Grade 1 reflux was determined in 7 cases and Grade 2 reflux was observed in 3 cases. Notably, only patients with Grade 2 reflux described worsening of their tinnitus symptoms during the examination and their daily activities as well.

Conclusions

NST might also be associated with hemodynamic problems of the venous system and the MRI protocol starting with TWIST accompanied with Valsalva maneuver is not well-known, yet seems to be a feasible and beneficial method to detect potential jugular venous reflux in NST patients.

Brachial Artery Wall Stiffness Assessment by Shear Wave Elastography: A Promising New Diagnostic Tool for Endothelial Dysfunction Detection

OBJECTIVES

This study was designed to measure the changes in brachial artery wall stiffness by shear wave elastography (SWE) and evaluate the accuracy of SWE changes for detection of endothelial dysfunction.

METHODS

Sixty-five consecutive participants (19 patients with atherosclerosis proven by coronary angiography, 16 healthy young adults, 15 patients with cardiovascular risk factors, and 15 healthy older adults between 50 and 60 years) were prospectively included in this study. They were examined in the same week by SWE, and flow-mediated dilatation was evaluated for each patient.

RESULTS

The mean flow-mediated dilatation values ± 2 SDs after forearm occlusion were 8.54% ± 1.4% in healthy young adults, 7.61% ± 1.4% in healthy older adults, 5.83% ± 0.7% in patients with risk factors (P < .001), and 3.81% ± 2.4% in patients with atherosclerosis (P < .001, with respect to the risk factor group). There was a significant decrease in stiffness measurements in parallel with the increase in flow-mediated dilatation: 19.9% ± 6.3% in healthy young adults, 16.3% ± 5.1% in healthy older adults, 9.8% ± 5.4% in patients with risk factors (P < .05 with respect to the group with no risk factors), and 7.8% ± 6.4% in patients with atherosclerosis (P < .001 with respect to the healthy older adults).

CONCLUSIONS

Shear wave elastography in combination with flow-mediated dilatation could be a promising, widely available noninvasive diagnostic tool for detecting endothelial dysfunction.

Evaluation of median nerve by shear wave elastography and diffusion tensor imaging in carpal tunnel syndrome

PURPOSE

The aim of the current study is to investigate the diagnostic role of shear-wave elastography and diffusion tensor imaging in patients with carpal tunnel syndrome.

MATERIAL AND METHODS

The study included a total of 77 wrists; 18 normal, 35 wrists with mild, 9 wrists with moderate and 15 wrists with severe carpal tunnel syndrome. Elastography of the median nerve was performed by defining the boundaries of a segment of the nerve at sagittal plane at the level of proximal carpal row. Additionally, the cross-sectional area of the median nerve was evaluated. Fractional anisotropy and apparent diffusion coefficient measurements were carried out by placing region-of-interest at three levels: at pisiform bone (carpal tunnel inlet), mid carpal tunnel, and hook of hamate (carpal tunnel outlet).

RESULTS

Patients with carpal tunnel syndrome had higher elasticity values of median nerve (53.0 kPa; IQR 40.8-77.0 kPa) compared to control subjects. (36.8 kPa; IQR 31.0-39.9 kPa) Patients with moderate-severe carpal tunnel syndrome had higher elasticity values (82 kPa; IQR 64.0-95.5 kPa) compared to patients with mild carpal tunnel syndrome. (44 kPa; IQR 32.5-59.5 kPa) Patients with carpal tunnel syndrome had lower fractional anisotropy at mid-carpal level (0.382; IQR 0.330-0.495) compared to the control group. (0.494; IQR 0.434-0.537) Patients with moderate-severe carpal tunnel syndrome had lower fractional anisotropy values (0.366; IQR 0.331-0.407) and higher apparent diffusion coefficient values (1.509 mm²/s; IQR 1.374-1.733 mm²/s) compared to patients with mild carpal tunnel syndrome. (0,423; IQR 0.324-0.526 and 1.293 mm²/s; IQR 0.967-1.514 mm²/s) CONCLUSION: Shear-wave elastography and diffusion tensor imaging are helpful imaging modalities in diagnosing carpal tunnel syndrome and assessing its severity.

Evaluation of parenchymal thyroid diseases with multiparametric ultrasonography

Aim:

Differential diagnosis of parenchymal thyroid diseases by gray-scale ultrasound is quite difficult for a radiologist as the findings are very similar to each other. In this study we aimed to assess some quantitative spectral Doppler parameters, resistivity index (RI), acceleration time (AT), and quantitative elastography [shear wave velocity (SWV)] together to show their reliability for differential diagnosis of parenchymal thyroid diseases.

Materials and Methods:

We retrospectively reviewed findings of 227 patients (179 females, 48 males) that underwent spectral Doppler ultrasound and acoustic radiation force impulse between October 2013 and March 2016. Ages of the patients were between 18 and 74 years (39.52 ± 12.67). Based on clinical and laboratory findings, patients were divided into five groups (N: Normal, EH: Early Hashimoto, H: Late Hashimoto, M: Nodular Thyroid Disease, HM: Hashimoto + Nodular Thyroid Disease). Detailed statistical analyses were done on parameters such as age, gender, volume information, and RI, AT (ms), SWV (m/s).

Results:

No significant effect of gender or volume on the differentiation of disease pattern (Chi-square test: P = 0.306, Kruskal-Wallis test: P = 0.290) was found in this study. RI (0.41 ± 0.06) and SWV values (1.19 ± 0.18 m/s) were the lowest. AT values (>55 ms) were the highest in EH group (area under the curve: 0.913). Existence of H decreased RI and SWV values, while it extended AT in a different thyroid disease.

Conclusion:

Thyroid parenchymal diseases could be classified and differentiated from each other by measuring RI, AT, and SWV values quantitatively. So, in suspicious cases, these parameters could be a reliable asset for differential diagnosis.

Apparent Diffusion Coefficient Measurement in Mediastinal Lymphadenopathies: Differentiation between Benign and Malignant Lesions

Objectives:

We aimed to prospectively assess the diagnostic value of apparent diffusion coefficient (ADC) measurement in the differentiation of benign and malignant mediastinal lymphadenopathies.

Materials and Methods:

The study included 63 consecutive patients (28 women, 35 men; mean age 59.3 years) with 125 mediastinal lymphadenopathies. Echoplanar diffusion-weighted magnetic resonance imaging of the mediastinum was performed with b-factors of 0 and 600 mm²/s before mediastinoscopy and mediastinotomy, and ADC values were measured. The ADC values were compared with the histological results, and statistical analysis was done. P < 0.05 was considered statistically significant.

Results:

The mean ADC value of malignant mediastinal lymphadenopathy (1.030 ± 0.245 × 10⁻³ mm²/s) was significantly lower (P < 0.05) when compared to benign lymphadenopathies (1.571 ± 0.559 × 10⁻³ mm²/s). For differentiating malignant from benign mediastinal lymphadenopathy, the best result was obtained when an ADC value of 1.334 × 10⁻³ mm²/s was used as a threshold value; area under the curve 0.848, accuracy 78.4%, sensitivity 66%, specificity of 86%, positive predictive value 76.7%, and negative predictive value of 79.2%. Interobserver agreement was excellent for ADC measurements.

Conclusions:

ADC measurements could be considered an important supportive method in differentiating benign from malignant mediastinal lymphadenopathies.

Elastography in Distinguishing Benign from Malignant Thyroid Nodules

AIM

The aim of this study is to test the diagnostic success of strain elastography in distinguishing benign from malignant thyroid nodules.

MATERIALS AND METHODS

The size, echogenicity, and halo integrity of 293 thyroid nodules and the presence of microcalcification in these nodules were evaluated on gray-scale examination. Doppler characteristics and elastography patterns were also evaluated and recorded. Nodules were classified in four categories (patterns 1-4) based on elastographic examination.

RESULTS

According to the cytopathological findings, 222 nodules were benign, and 71 nodules were malignant. The risk of a nodule to be malignant was 3.8 times increased by hypoechogenicity, 7.7 times increased by the presence of microcalcification, and 11.5 times increased by the absence of halo. On Doppler patterns, the presence of central vascularity increased the malignancy risk of a nodule by 5.8 times. According to the receiver operating characteristic analysis, patterns 3 and 4 were malignant, and patterns 1 and 2 were benign. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of elastography were 100%, 80.2%, 61.7%, 100%, and 85%, respectively.

CONCLUSION

Strain elastography can be used as a noninvasive method in distinguishing benign from malignant thyroid nodules and in identifying the patients who would undergo surgery.

A dilemma at gray scale thyroid ultrasound: microcalcification or not? Differentiation with Acoustic Radiation Force Impulse Imaging-Virtual Touch Imaging

AIMS

To evaluate the capacity of virtual touch imaging (VTI) of the acoustic radiation force impulse (ARFI) techniquein the differential diagnosis of micro-echogenicities in thyroid nodules.

MATERIAL AND METHODS

The study comprised 28patients. Gray scale and ARFI displacement maps were used during ultrasound examination.In the same session, fine needleaspiration biopsy (FNAB) samples were obtained from the dominant nodule hav-ing micro-echogenicities. Two radiologists blinded to the FNAB results and clinical data of the patients evaluated these images and rated ARFI echogenicities according to the degree of shining points on the displacement maps and classified them as isohypoechogenic, isohyperechogenic, and obvious hyperechogenic. To differentiate between benignancy and malignancy, "a new sign" was defined as follows: in the ARFI maps obtained by VTI, iso-echogenic or hyper-echogenic appearance of micro-echogenic foci was evaluated as benignancy and hypo-echogenic appearance of micro-echogenic foci was evaluated as malignancy.

RESULTS

The FNAB results indicated 14 cases and benign nodules in the other 14 cases. Interobserver agreement between the two radiologists was highly significant for the classification of the micro-echogenic foci (Kappa=0.659, p<0.001). When we reclassified the hyperechoic and isohyperechoic foci as "benign" and isohypoechoic foci as "malignant", the interobserver agreement between the two radiologists increased (Kappa=0.772, p<0.001). The evaluation of the first and second radiologists were highly concordant with the gold standard pathology results (Kappa=0.786, p<0.001 and Kappa=0.714, p<0.001, respectively).

CONCLUSIONS

ARFI method with specific VTI features could be a very useful tool in the differentiation of malignant microcalcifications in thyroid nodules.

Is There Any Difference Between Seminomas and Nonseminomatous Germ Cell Tumors on Shear Wave Elastography? A Preliminary Study

OBJECTIVES

The purpose of this study was to evaluate the ability of shear wave elastography (SWE) to differentiate seminomas from nonseminomatous germ cell tumors.

METHODS

Approval for this retrospective study was obtained from the local Ethics Committee of Istanbul University Cerrahpasa Medical School. Fifteen patients with malignant testicular lesions were examined by grayscale sonography, color or power Doppler sonography, and SWE between February 2011 and October 2015. The size of each lesion, Doppler signal parameters, echogenicity, presence of microlithiasis, unifocality or multifocality, and histopathologic findings were the main factors evaluated.

RESULTS

The mean age of the patients was 33 years (range, 25-55 years). There were no differences between seminomas and nonseminomatous germ cell tumors in terms of Doppler signals, echogenicity, microlithiasis, or focality. Only the homogeneous and heterogeneous echogenicity patterns differed significantly. However, a significant difference was evident in SWE-derived quantitative data.

CONCLUSIONS

Seminomas and nonseminomatous germ cell tumors do not differ significantly on grayscale or Doppler sonography, except in terms of homogeneity. However, SWE seems to differentiate seminomas from nonseminomatous germ cell tumors.

Defining the Collateral Flow of Posterior Tibial Artery and Dorsalis Pedis Artery in Ischemic Foot Disease: Is It a Preventing Factor for Ischemia?

BACKGROUND

Critical limb ischemia, a worldwide prevalent morbidity cause, is mostly secondary to vascular insufficiency due to atherosclerosis. The disease presents with intermittent claudication, which can progress to critical limb ischemia requiring amputation. Research has emphasized that the quality or existence of the pedal arch have a direct effect on wound healing and, therefore, on limb salvage, through the mechanism of collateral vascularization to the ischemic regions.

OBJECTIVES

This study aimed to determine the existence and, if present, grade of retrograde blood flow from plantar arch to dorsal foot artery (dorsalis pedis artery, DPA). The correlation between clinical symptoms and presence of collateral flow were also investigated.

PATIENTS AND METHODS

Study group consisted of 34 cases, which included patient group (n = 17, all male, mean age: 68 years) and control group (n = 17, all male, mean age: 66 years). After physical examination and lower extremity Doppler examination, spectral morphology of DPA flow was recorded, before and during manual compression of posterior tibial artery (PTA), for a period of 5 seconds. At the end, findings of Doppler ultrasound, computed tomography angiography, magnetic resonance angiography and, physical examination finding and symptomatology were gathered and analyzed.

RESULTS

In the patient group, 31 lower limb arteries, of total of 17 cases, were included. After compression maneuver, DPA in 11 cases (six right, five left) showed retrograde filling from plantar arch. This retrograde flow support was triphasic in three cases, biphasic in five cases, and monophasic in three cases. In other DPAs of these 20 limbs, PTA based retrograde collateral flow was not determined. In nine of these 20 limbs, with no or diminished retrograde filling, symptoms were worse than in other cases. Contrarily, only two of 11 limbs, with retrograde collaterals, have claudication during walking.

CONCLUSION

In cases with critical atherosclerotic disease of anterior tibial artery, PTA-based biphasic or triphasic retrograde collateral flow prevents ischemia, whereas monophasic support or no retrograde flow remains incapable.

In Vivo Evaluation of the Biomechanical Properties of Optic Nerve and Peripapillary Structures by Ultrasonic Shear Wave Elastography in Glaucoma

Background

Primary open-angle glaucoma is a multifactorial serious disease characterized by progressive retinal ganglion cell death and loss of visual field.

Objectives

The purposes of this study were to investigate shear wave elastography (SWE) use in the evaluation of the optic nerve (ON) and peripapillary structures, and to compare the findings between glaucomatous and control eyes.

Patients and Methods

A case-controlled study, including 21 patients with primary open-angle glaucoma and 21 age-matched control subjects, was carried out. All of the participants had comprehensive ophthalmological exams that included corneal biomechanical measurements with ocular response analyzer. In vivo evaluation of the biomechanical properties of the ON and peripapillary structures were performed with SWE in all participants. The Kolmogorov–Smirnov test was used to analyze the normal distribution of data. Differences of parameters in ophthalmologic data and stiffness values of patients with and without glaucoma were evaluated using the Mann-Whitney U test.

Results

There were no statistically significant differences between the glaucoma and control groups in terms of age (P > 0.05) and gender (P > 0.05). Corneal hysteresis was lower in the glaucoma group (P < 0.05). Corneal compensated intraocular pressure and Goldmann correlated intraocular pressure were higher in the glaucoma group (P < 0.0001 for both). The mean stiffness of the ON and peripapillary structures were significantly higher in glaucoma patients for each measured region (P < 0.05).

Conclusion

The study evaluated the biomechanical properties of the ON and peripapillary structures in vivo with SWE in glaucoma. We observed stiffer ON and peripapillary tissue in glaucomatous eyes, indicating that SWE claims new perspectives in the evaluation of ON and peripapillary structures in glaucoma disease.

Magnetic Resonance Imaging in Diagnosis and Monitoring of Hepatocellular Carcinoma in Liver Transplantation: A Comprehensive Review

Hepatocellular carcinoma (HCC) is the most common primary liver cancer. One of the most important risk factors of HCC is cirrhosis. The optimal treatment of HCC is liver transplantation, since it treats both the underlying cirrhosis and the cancer. Patients that have risk factors should be included in surveillance programs since HCC can be cured only during the early stages. Surveillance can be performed by ultrasonography (US), which is an inexpensive, non-invasive, and widely available technique, but it is considered to have a low sensitivity. If a suspicious lesion is detected on US exam, computerized tomography (CT) or magnetic resonance imaging (MRI) can be used to further evaluate this lesion. MRI is considered to be superior to CT because it has greater contrast resolution and tissue characterization. In this article, we present a review of MRI for HCC in liver transplantation (LT) with a focus on characteristic MR features of this tumor and current guidelines.

Aneurysmal Bone Cyst of Sphenoid Bone and Clivus Misdiagnosed as Chordoma: A Case Report

Aneurysmal bone cysts (ABCs) are benign and rapidly expanding bone destructive lesions of any bone. They are commonly localized in the metaphysis of long bones, whereas skull base ABCs are rare. We report a case of a 21-year-old man who had been misdiagnosed as chordoma and undergone surgery. However, histopathological examination revealed it to be an ABC.

Perianal Fistula With and Without Abscess: Assessment of Fistula Activity Using Diffusion-Weighted Magnetic Resonance Imaging

Background:

Magnetic resonance imaging (MRI) is highly accurate for the depiction of both the primary tract of fistula and abscesses, in patients with perianal disease. In addition, MRI can be used to evaluate the activity of fistulas, which is a significant factor for determining the therapeutic strategy.

Objectives:

This study aimed to determine the usefulness of diffusion-weighted (DW) MRI for assessing activity and visibility of perianal fistula.

Patients and Methods:

Fifty-three patients with 56 perianal fistulas were included in the current retrospective study. The T2-weighted imaging (T2WI) and DWMRI were performed and apparent diffusion coefficient (ADC) values of fistulas were measured. Fistulas were classified into two groups: only perianal fistulas and fistulas accompanied by abscess. Fistulas were also classified into two groups, based on clinical findings: positive inflammatory activity (PIA) and negative inflammatory activity (NIA).

Results:

Mean ADC value (mm²/s) of PIA group was significantly lower than that of NIA group, regarding lesions in patients with abscess-associated fistulas (1.371 × 10^-3 ± 0.168 × 10^-3 vs. 1.586 × 10^-3 ± 0.136 × 10^-3; P = 0.036). No statistically significant difference was found in mean ADC values between PIA and NIA groups, in patients with only perianal fistulas (P = 0.507). Perianal fistula visibility was greater with combined evaluation of T2WI and DWMRI than with T2WI, for two reviewers (P = 0.046 and P = 0.014).

Conclusion:

The DWMRI is a useful technique for evaluating activity of fistulas with abscess. Perianal fistula visibility is greater with combined T2WI and DWMRI than T2WI alone.

Thoracic splenosis after a gunshot: diffusion-weighted MRI findings

BACKGROUND

Intrathoracic splenosis is a rare condition resulting from concomitant rupture of the spleen and left hemidiaphragm after a traumatic event involving the spleen and the diaphragma and is defined as autotransplantation of splenic tissue in thorax.

CASE REPORT

The aim of this study was to present a case report of a combined intrathoracic and subcutaneous splenosis in a patient 19 years after penetrating trauma. She has left dorsal side pain and routine chest roentgenogram shows pleural nodular masses. The patient was referred to us for radiologic work up.

CONCLUSIONS

The MRI scans revealed the intrathoracic and subcutan masses as mainly hypointense on T1-weighted images and hyperintense on T2-weighted images and significant restriction in diffusion-weighted images. Scintigraphy revealed abnormal hot spots in subcutaneous tissue and diaphragmatic pleura of the left hemithorax.

Typical MDCT Angiography Findings of an Unusual Cutaneous Neoplasia; Masson Tumor

Background

Intravascular papillary endothelial hyperplasia (IPEH), also known as masson tumour, is a lesion composed of proliferating endothelial cells.

Case Report

In this article we explained clinical, histological and radiological features of IPEH involving the scalp, localized on the left side of the skull and in the periauricular region.

Conclusions

Radiologically, intravascular papillary endothelial hyperplasia could be misdiagnosed as malignant or benign vascular tumour. On cross-sectional imaging it is useful demonstrating the extremely vascular component of IPEH. But IPEH has no specific radiologic features that we can use to differentiate from the aforementioned lesions. Due to that, histopathological examinations are needed to diagnose IPEH.

Percutaneous transcatheter embolization of gastrointestinal bleeding in a child with polyarteritis nodosa

Background

Polyarteritis nodosa is a form of necrotizing vasculitis of small and medium-sized arteries. Major gastrointestinal complications are ulceration, perforation, hemorrhage, and obstruction.

Case Report

We report on a clinical case of a 16-year-old female patient with massive hematemesis, who was successfully treated with embolization with a 1:2 dilution of N-butyl cyanoacrylate glue.

Conclusions

To the best of our knowledge, this is the youngest child reported on with massive GI bleeding secondary to PAN, treated with successful percutaneous transcatheter embolization under emergency conditions.

Evaluation of Liver Stiffness After Radioembolization by Real-Time ShearWave™ Elastography: Preliminary Study

PURPOSE

To evaluate the effect of ShearWave(™) elastography (SWE) for the assessment of liver fibrosis after radioembolization (RE) in patients with liver malignancies.

MATERIALS AND METHODS

We prospectively examined the effects of SWE before and after RE in 17 adult patients, from June 2012 to September 2013. All patients underwent SWE within 1 month before and 3 months (96.3 ± 22.9 days) after RE. Measurements were taken in segments III, IV, V, and VI (lateral/medial left lobe and anterior/posterior right lobe, respectively). Liver stiffness was studied in the 39 treated segments.

RESULTS

The mean stiffness of liver tissue according to the pre-RE SWE measurements was not different from the post-RE SWE measurements in the segments that did not undergo RE. Conversely, segments treated with RE were significantly stiffer according to the post-RE SWE measurements (mean SWE 17.4 kPa) than according to the baseline measurements (7.0 kPa) (p < 0.001). Patients with hepatocellular carcinoma and preexisting infection with hepatitis B and C viruses had higher pre-embolization stiffness, and the post-embolization stiffness of the treated segments in these patients was higher than that in the remainder of the study population.

CONCLUSION

These data suggest that SWE measurements of liver stiffness increase as early as the third month after RE. SWE could be used as a noninvasive complementary imaging method for preliminary assessment of liver fibrosis before and after RE.

Life-threatening complication of percutaneous transthoracic fine-needle aspiration biopsy: systemic arterial air embolism

Computed tomography-guided percutaneous transthoracic fine-needle aspiration biopsy of lung lesions is a well known diagnostic technique. Nevertheless, it has some complications; such as pneumothorax, intraparenchymal hemorrhage and hemoptysis, which are not rare. Air embolism is one of the rare but potentially fetal complications of this procedure. Herein, we report the case of a 69-year-old male, in which case of systemic air embolism developed after the performance of lung biopsy. Early diagnosis and prompt oxygen therapy is crucial for patient's survival so careful reviewing of the obtained computed tomography images during the biopsy may prevent a missing systemic air embolism and provide an adequate therapy.

Simultaneous thrombosis of superior mesenteric artery and superior mesenteric vein following chemotherapy: MDCT findings

A case of acute mesenteric ischemia due to thrombosis of superior mesenteric artery and vein in a 44-year-old woman following chemotherapy for invasive laryngeal carcinoma was diagnosed on a multi-detector CT scan. Although the link between malignancy and thromboembolism is widely recognized in patients with cancer, chemotherapy further elevates the risk of thrombosis. Acute mesenteric ischemia associated or not associated with chemotherapy rarely occurs in patients with cancer. Moreover, co-occurrence of superior mesenteric artery and superior mesenteric vein thrombosis is reported for the first time.

Adult diagnosis of Swyer-James-Macleod syndrome

Swyer-James-Macleod syndrome (SJMS) is a rare, complex disease characterised by unilateral hyperlucent lung or lobe owing to loss of pulmonary vasculature and alveolar hyperdistention. Patients with SJMS may be asymptomatic at diagnosis, but its differential diagnosis with asthma is difficult. Almost all the reported cases of SJMS were managed by conservative therapy, comprising prevention and treatment of recurrent pulmonary infections.