Detection of virus-specific T cells via ELISpot corroborates early diagnosis in human Borna disease virus 1 (BoDV-1) encephalitis

BACKGROUND

Within endemic regions in southern and eastern Germany, Borna disease virus 1 (BoDV-1) causes rare zoonotic spill-over infections in humans, leading to encephalitis with a high case-fatality risk. So far, intra-vitam diagnosis has mainly been based on RT-qPCR from cerebrospinal fluid (CSF) and serology, both being associated with diagnostic challenges. Whilst low RNA copy numbers in CSF limit the sensitivity of RT-qPCR from this material, seroconversion often occurs late during the course of the disease.

CASE PRESENTATION

Here, we report the new case of a 40 - 50 year-old patient in whom the detection of virus-specific T cells via ELISpot corroborated the diagnosis of BoDV-1 infection. The patient showed a typical course of the disease with prodromal symptoms like fever and headaches 2.5 weeks prior to hospital admission, required mechanical ventilation from day three after hospitalisation and remained in deep coma until death ten days after admission.

RESULTS

Infection was first detected by positive RT-qPCR from a CSF sample drawn four days after admission (viral load 890 copies/mL). A positive ELISpot result was obtained from peripheral blood collected on day seven, when virus-specific IgG antibodies were not detectable in serum, possibly due to previous immune adsorption for suspected autoimmune-mediated encephalitis.

CONCLUSION

This case demonstrates that BoDV-1 ELISpot serves as additional diagnostic tool even in the first week after hospitalisation of patients with BoDV-1 encephalitis.

Multiparametric Sonographic Imaging of Thyroid Lesions: Chances of B-Mode, Elastography and CEUS in Relation to Preoperative Histopathology

Simple Summary

As the incidence of thyroid lesions in Europe is rising, more and more people affected by thyroid pathologies seek treatment in a clinic. Every suspicious thyroid nodule needs to be confirmed as benign or malignant in order to be treated correctly. Unnecessary invasive diagnostics and thyroid surgery should be avoided. The aim of this retrospective study was to improve the distinction between benign and malignant nodules by using new high-performance multiparametric ultrasound examination techniques. By analyzing 122 thyroid nodules we created a score-based system combining B-mode, shear-wave elastography and contrast-enhanced ultrasound malignancy criteria. This system allows for a quite accurate detection of thyroid carcinomas with a sensitivity of 95% and specificity of 75.49%. Shear-wave elastography and contrast-enhanced ultrasound can detect unique malignancy features, which cannot be found in B-mode. Therefore, these criteria would present a relevant addition to the B-mode TI-RADS classification.

Abstract

Background: The aim was to improve preoperative diagnostics of solid non-cystic thyroid lesions by using new high-performance multiparametric ultrasound examination techniques. Methods: Multiparametric ultrasound consists of B-mode, shear-wave elastography and contrast enhanced ultrasound (CEUS) including Time-Intensity-Curve (TIC) analysis. A bolus of 1–2.4 mL Sulfur Hexafluorid microbubbles was injected for CEUS. Postoperative histopathology was the diagnostic gold standard. Results: 116 patients were included in this study. 102 benign thyroid nodules were diagnosed as well as 20 carcinomas. Suspicious B-mode findings like microcalcifications, a blurry edge and no homogeneous sonomorphological structure were detected in 60, 75 and 80% of all carcinomas but only in 13.7, 36.3 and 46.1% of all benign lesions. The average shear-wave elastography measurements of malignant lesions (4.6 m/s or 69.8 kPa centrally and 4.2 m/s or 60.1 kPa marginally) exceed the values of benign nodules. Suspicious CEUS findings like a not-homogeneous wash-in and a wash-out were detected almost twice as often in carcinomas. Conclusion: Multiparametric ultrasound offers new possibilities for the preoperative distinction between benign and malignant thyroid nodules. A score based system of B-mode, shear-wave and CEUS malignancy criteria shows promising results in the detection of thyroid carcinomas. It reaches a sensitivity of 95% and specificity of 75.49%.

Dynamic endoluminal contrast enhanced ultrasound (CEUS) for display of drainages in inflammatory abdominal fluid collections1

AIM

To evaluate the additive clinical value of endoluminal contrast enhanced ultrasound (CEUS) after interventional placement of drainages in abdominal fluid collections.

MATERIAL/METHOD

Examination of 30 patients using a 1-6 MHz convex probe (Resona 7, Mindray) to locate the fluid collection in B-Mode. Additionally, dynamic endoluminal CEUS with 1 ml sulphur-hexafluoride microbubbles was performed to measure the extent of the percutaneously drained abscesses. Independent assessment of dynamically stored images in PACS in DICOM format. Correlation to reference imaging using computed tomography (CT).

RESULTS

A total of 30 patients were examined (17 m, 19-78 years, mean 56.1 years). Drainages were positioned in the liver in 15 cases, in the pelvis after kidney transplantation in 4 cases, close to the spleen in 1 case and in the abdomen in 10 cases. In all cases abscesses showed marginal hyperaemia with reactive septations in CEUS. The drainage position was assessed by means of B-mode in all cases first and then by CEUS. In 4 cases CEUS showed a fistula to the pleura, in 5 cases to the peritoneum, in 2 cases to the intestine, in 5 cases to the biliary tract, corresponding to the CT. In 2 cases there was a hint of an anastomotic leakage after intestinal anastomosis, which was reliably detected by CT. The drainage was removed in 11 cases within a period of 2 to 5 days after CEUS control, in 9 cases within a period of 5 to 10 days. Another operation was necessary in 3 cases. A new drainage was placed in 2 cases. The required amount of contrast medium is 1 ml endoluminally diluted to 9 ml sodium chloride.

CONCLUSION

CEUS facilitates the exact localization and characterization of inflammatory abdominal fluid collections. Furthermore, possible fistulas can be detected that cannot be seen with conventional ultrasound.

Necessity of Immediate MRI Imaging in the Acute Care of Severely Injured Patients

Background and Objectives: The standard diagnostic procedure for a patient with a suspected polytrauma injury is computed tomography (CT). In individual cases, however, extended acute imaging using magnetic resonance imaging (MRI) can provide valuable and therapy-relevant information. The aim of our cohort study was to find such cases and to describe their characteristics in order to be able to give possible recommendations for MRI application in acute trauma situations. Materials and Methods: In the study period from 2015-2019, an evaluation of the imaging performed on polytrauma patients was carried out. The specific diagnostic and therapeutic criteria of the MRI group were further defined. Results: In total, 580 patients with an ISS ≥16 (injury severity score) were included in the study. Of these 580 patients, 568 patients received a CT scan and 12 patients an MRI scan as part of the initial diagnostic. Altogether, 66.67% of the MRIs took place outside of regular service hours. The main findings for MRI indications were neurological abnormalities with a focus on myelon injuries. Further MRI examinations were performed to rule out vascular injuries. All in all, 58.3% of the MRIs performed resulted in modified therapeutic strategies afterward. Conclusions: MRI in the context of acute diagnostic of a severely injured patient will likely remain reserved for special indications in the future. However, maximum care hospitals with a high flow of severely injured patients should provide 24/7 MR imaging to ensure the best possible care, especially in neurological and blunt vascular injuries.

Contrast-enhanced ultrasound perfusion imaging of organs

In multimodal radiologic imaging, contrast-enhanced ultrasound (CEUS) is increasingly used. One of the advantages of CEUS is the possibility of repeated application of contrast media without decreasing renal function or affecting the thyroid gland. Small solid liver lesions can be diagnosed and detected with high accuracy. Moreover, solid lesions in other abdominal organs can also be characterized. Frequent applications for solid lesions in the near field concern thyroid tumors and lymph nodes. For prostate diagnostics, CEUS can be used with an endorectal probe and perfusion imaging. This review explains how the additional (semi-)quantitative perfusion analysis, especially time-intensity curve (TIC) analyses, and wash-in/wash-out kinetics of integrated or external perfusion software programs facilitate new options in dynamic assessment of microvascularization during tumor follow-up care and even minimally invasive tumor therapy.

High-performance sonographical multimodal imaging of non cystic thyroid lesions: Chances of the preoperative diagnostics in relation to histopathology

AIM:

To improve preoperative diagnostics of solid non-cystic thyroid lesions by using new high-performance ultrasound techniques: optimized B-mode morphology, elastography, Color-Coded Doppler-Sonography (CCDS) and contrast enhanced ultrasound (CEUS)

MATERIALS AND METHODS:

In 33 cases solid, non-cystic thyroid lesions were rated as TIRADS 3 and up from conventional B-mode examinations. Additional high resolution Power Doppler including HR- and Glazing-Flow as optimized macrovascularization techniques, shear wave elastography and CEUS were performed on these patients by one experienced examiner. For CEUS a bolus of 1–2.4 ml Sulfurhexafluorid microbubbles (SonoVue®, Bracco, Milan, Italy) was injected into a cubital vein and then the distribution kinetics of the contrast agent were documented from the early arterial phase (10 to 15 seconds after injection) to the late venous phase (5 minutes after injection). Postoperative histopathology was the diagnostic gold standard as it provides the most reliable proof.

RESULTS:

33 patients (13 males, 20 females; age 29 –77 years; mean 55 years; SD 13 years) were included in this study. 28 of them had benign regressive thyroid nodules, 3 had adenomas and 4 were diagnosed with carcinomas (3 were histologically identified as papillary thyroid carcinomas, one as a medullary thyroid carcinoma). The volume of the thyroid gland ranged from 6.6 to 401.3 cm² (mean 72.6±92.0 cm²).

The adenoma diameters ranged from 9 to 40 mm (mean 22±16 mm) and the carcinoma diameters ranged from 19 to 33 mm (mean 26±6 mm). The 3 adenomas had different echogenicities: One was completely echofree, one was hypoechoic and one isoechoic. The 4 carcinomas however were equally characterized as hypoechoic and echofree. Two of three adenomas and all of the carcinomas showed an incomplete or diffuse margin. Micro-calcifications were found in one adenoma and in every carcinoma. However, no micro-calcifications were observed in cases of benign regressive nodules.

Performing shear-wave elastography the adenomas showed lower values than the carcinomas: The tissue velocity of the adenomas ranged from 2.86 m/s to 3.85 m/s (mean 3.32±0.5 m/s) and in carcinomas from 3.89 m/s to 5.66 m/s (mean 4.18±0.3 m/s).

Marginal hypervascularization was detected in two adenomas after applying CCDS. One adenoma was hypovascularized. The four carcinomas showed an irregular extreme hypervascularization along their margins as well as an irregular central normo- or hypervascularization in CCDS. The additional HR-Flow helped reducing artefacts.

In CEUS the dynamic capillary microvascularization of all carcinomas was very irregular with early enhancement and followed by partial or complete wash-out. In CEUS two adenomas had no wash-out and the other one showed a partial wash-out.

CONCLUSION:

Using modern multimodal imaging offers new possibilities for the differentiation between benign and malignant thyroid lesions. It is a very important diagnostic tool in addition to the B-Mode TIRADS classification and eases the decision between TIRADS 3, 4 and 5. However, additional multicenter studies are required for more detailed evaluations.

Contrast-enhanced ultrasound (CEUS) and perfusion imaging using VueBox®

The external perfusion software (VueBox™) for contrast-enhanced ultrasound (CEUS), enables the quantitative analysis of micro-vascularization within non-cystic lesions in terms of characterization and detection. This review summarizes our work about parathyroid gland, thyroid gland, liver, prostate and other tissues as well as original studies in the use of parametric perfusion imaging. Useful perfusion parameters are introduced.

Contrast enhanced ultrasound (CEUS) with parametric imaging after irreversible electroporation (IRE) of the prostate to assess the success of prostate cancer treatment

AIM

The aim of this study was to assess the success of irreversible electroporation (IRE) in prostate cancer and to differentiate between reactive changes and tumor.

MATERIAL AND METHODS

This is a retrospective pilot study of 50 patients after irreversible electroporation (IRE) in prostate cancer between 50-79 years (mean age 65 years). Each patient received a transabdominal sonography using a 1-6 MHz convex matrix probe. Contrast-enhanced ultrasound (CEUS) was performed after i.v. bolus injection of 2.0 ml sulphur hexafluoride microbubbles. DICOM loops were continuously stored up to one minute. Parametric images were calculated by integrated perfusion analysis software. A comparison was drawn to a follow-up MRI six months after ablation.

RESULTS

While 13 patients showed local recurrence, 37 patients were successfully treated, meaning no local recurrence within six months after ablation. 18 patients showed signs of prostatitis after IRE. Tumorous changes were visually characterized by dynamic early nodular hypervascularization with fast and high wash-in. Correspondingly, nodular red and yellow shades were seen in parametric imaging. All patients with remaining tumor were correctly identified with CEUS and parametric imaging. After IRE there is a relevant decrease in tumor microcirculation in all patients, as seen in more purple shades of the prostate. The sensitivity for detecting residual tumor with CEUS compared to MRI was 76%, the specificity was 81%. The corresponding positive predictive value (PPV) was 73% and the negative predictive value (NPV) was 83%.

CONCLUSION

CEUS and parametric imaging enable a critical analysis of post-ablation defects after IRE for prostate cancer even with a transabdominal approach. Remaining tumor can be detected with the help of pseudo-colors.

Contrast-Enhanced Ultrasound Algorithms (CEUS-LIRADS/ESCULAP) for the Noninvasive Diagnosis of Hepatocellular Carcinoma - A Prospective Multicenter DEGUM Study

BACKGROUND

 This prospective multicenter study funded by the DEGUM assesses the diagnostic accuracy of standardized contrast-enhanced ultrasound (CEUS) for the noninvasive diagnosis of hepatocellular carcinoma (HCC) in high-risk patients.

METHODS

 Patients at high risk for HCC with a histologically proven focal liver lesion on B-mode ultrasound were recruited prospectively in a multicenter approach. Clinical and imaging data were entered via online entry forms. The diagnostic accuracies for the noninvasive diagnosis of HCC were compared for the conventional interpretation of standardized CEUS at the time of the examination (= CEUS on-site) and the two CEUS algorithms ESCULAP (Erlanger Synopsis for Contrast-enhanced Ultrasound for Liver lesion Assessment in Patients at risk) and CEUS LI-RADS (Contrast-Enhanced UltraSound Liver Imaging Reporting and Data System).

RESULTS

 321 patients were recruited in 43 centers; 299 (93.1 %) had liver cirrhosis. The diagnosis according to histology was HCC in 256 cases, and intrahepatic cholangiocarcinoma (iCCA) in 23 cases. In the subgroup of cirrhotic patients (n = 299), the highest sensitivity for the diagnosis of HCC was achieved with the CEUS algorithm ESCULAP (94.2 %) and CEUS on-site (90.9 %). The lowest sensitivity was reached with the CEUS LI-RADS algorithm (64 %; p < 0.001). However, the specificity of CEUS LI-RADS (78.9 %) was superior to that of ESCULAP (50.9 %) and CEUS on-site (64.9 %; p < 0.001). At the same time, the negative predictive value (NPV) of CEUS LI-RADS was significantly inferior to that of ESCULAP (34.1 % vs. 67.4 %; p < 0.001) and CEUS on-site (62.7 %; p < 0.001). The positive predictive values of all modalities were high (around 90 %), with the best results seen for CEUS LI-RADS and CEUS on-site.

CONCLUSION

 This is the first multicenter, prospective comparison of standardized CEUS and the recently developed CEUS-based algorithms in histologically proven liver lesions in cirrhotic patients. Our results reaffirm the excellent diagnostic accuracy of CEUS for the noninvasive diagnosis of HCC in high-risk patients. However, on-site diagnosis by an experienced examiner achieves an almost equal diagnostic accuracy compared to CEUS-based diagnostic algorithms.

Bornavirus Encephalitis Shows a Characteristic Magnetic Resonance Phenotype in Humans

OBJECTIVE

The number of diagnosed fatal encephalitis cases in humans caused by the classical Borna disease virus (BoDV-1) has been increasing, ever since it was proved that BoDV-1 can cause human infections. However, awareness of this entity is low, and a specific imaging pattern has not yet been identified. We therefore provide the first comprehensive description of the morphology of human BoDV-1 encephalitis, with histopathological verification of imaging abnormalities.

METHODS

In an institutional review board-approved multicenter study, we carried out a retrospective analysis of 55 magnetic resonance imaging (MRI) examinations of 19 patients with confirmed BoDV-1 encephalitis. Fifty brain regions were analyzed systematically (T1w, T2w, T2*w, T1w + Gd, and DWI), in order to discern a specific pattern of inflammation. Histopathological analysis of 25 locations in one patient served as correlation for MRI abnormalities.

RESULTS

Baseline imaging, acquired at a mean of 11 ± 10 days after symptom onset, in addition to follow-up scans of 16 patients, revealed characteristic T2 hyperintensities with a predilection for the head of the caudate nucleus, insula, and cortical spread to the limbic system, whereas the occipital lobes and cerebellar hemispheres were unaffected. This gradient was confirmed by histology. Nine patients (47.4%) developed T1 hyperintensities of the basal ganglia, corresponding to accumulated lipid phagocytes on histology and typical for late-stage necrosis.

INTERPRETATION

BoDV-1 encephalitis shows a distinct pattern of inflammation in both the early and late stages of the disease. Its appearance can mimic sporadic Creutzfeldt-Jakob disease on MRI and should be considered a differential diagnosis in the case of atypical clinical presentation. ANN NEUROL 2020;88:723-735.

Color coded perfusion analysis and microcirculation imaging with contrast enhanced ultrasound (CEUS) for post-interventional success control following thermal ablative techniques of primary and secondary liver malignancies

AIM

Evaluation of the post-interventional success following ablative techniques (radiofrequency and microwave) using a new color coded perfusion quantification software with CEUS in patients with primary and secondary liver malignancies.

MATERIAL AND METHODS

75 patients (60 males, 15 females, age 24-84 years, mean 62.7 years) with 128 malignant liver lesions were included in this study. Between 01/2013 and 06/2018, the therapeutic interventional procedure in 88 lesions was MWA, in 40 lesions RFA. All patients underwent CEUS using a convex multifrequency probe (1-6 MHz) following application of 1-2.4 ml sulphur hexaflouride microbubbles, before and within 24 hours following RFA and MWA to detect residual tumor tissue. Postprocessing of the stored DICOM loops from 15 sec up to 1 min using a perfusion quantification software regarding peak enhancement (pE), time to peak (TTP), mean transit time (MTT), rise time (Ri) and Wash-in area under the curve (WiAUC) in the center of the lesion, the border area and periphery was performed.

RESULTS

In patients treated with RFA, pE differences between center of the lesion vs. surrounding liver were found to be statistically extremely significant (p < 0.001), differences between center of the lesion and margin were also statistically significant (p < 0.01). mTT, TTP, WiAuC and Ri showed no significant difference between center, margin or surrounding liver.In patients treated with MWA, statistically significant differences (p < 0.05) were found for pE, Ri and mTT regarding the differences between center of lesion and surrounding tissue. WiAuC and TTP showed no significant differences between center, margin or surrounding liver.

CONCLUSION

CEUS with perfusion imaging is a valuable supporting tool for post-interventional success control following RFA and MWA of primary and secondary liver maligancies. Focus should be placed upon pE following MWA and pE, Ri and mTT following RFA.

Color Coded Perfusion Imaging with Contrast Enhanced Ultrasound (CEUS) for Post-Interventional Success Control Following Irreversible Electroporation (IRE) of Primary and Secondary Malignant Liver Lesions

Aim: Evaluation of the post-interventional success following irreversible electroporation (IRE) using a new color coded perfusion quantification software with contrast-enhanced ultrasound (CEUS) in patients with malignant lesions of the liver. Methods: Thirty-eight patients with 68 malignant liver lesions underwent IRE. All malignant lesions were investigated with CEUS before and within 24 hours following IRE to detect residual tumor tissue. The parameters analyzed by color coded perfusion quantification software were: the peak enhancement (pE), time to peak (TTP), mean transit time (mTT), rise (Ri) and wash-in area under the curve (WiAUC). Perfusion in the center, the margins of the lesions and in the surrounding liver were evaluated using these parameters. Results: Hepatocellular carcinoma (HCC) with complete ablation showed significantly different changes between the center and the margin of the lesions for WiAUC (p<0.05) and pE (p<0.01). Also significant differences were noted between the center of the lesions and the surrounded tissue for the same parameters (p<0.01). In the completely ablated metastatic lesions, significant differences were found between the center of the lesion and the margins (p < 0.01) and between the center of the lesion and the surrounding liver (p < 0.05) for WiAUC. mTT, TTP and Ri showed no significant changes between the center of the lesions, margin of the lesions or surrounding tissue. Also, no significant differences were found for these parameters in the different regions of interest for HCC or the metastatic lesions with partial ablation success. Conclusion: CEUS with perfusion imaging is a valuable supporting tool for the post-interventional evaluation of liver lesions following IRE. Focus should be placed on the peak enhancement (pE) and the wash-in area under the curve (WiAUC).

Color coded perfusion imaging with contrast enhanced ultrasound (CEUS) for post-interventional success control following trans-arterial chemoembolization (TACE) of hepatocellular carcinoma

Aim

Evaluation of an external color coded perfusion quantification software with CEUS for the post-interventional success control following TACE in patients with HCC.

Material and methods

31 patients (5 females, 26 males, age range 34–82 years, mean 66.8 years) with 59 HCC lesions underwent superselective TACE using DSM Beads between 01/2015 and 06/2018. All patients underwent CEUS by an experienced examiner using a convex multifrequency probe (1–6 MHz) within 24 hours following TACE to detect residual tumor tissue. Retrospective evaluation using a perfusion quantification software regarding pE, TTP, mTT, Ri and WiAUC in the center of the lesion, the margin and surrounding liver.

Results

In all lesions, a post-interventional visual reduction of the tumor microvascularization was observed. Significant differences between center of the lesion vs. margin and surrounding liver were found regarding peak enhancement (867.8 ± 2416 center vs 2028 ± 3954 margin p<0.005) and center 867.8 ± 2416 vs 2824 ± 4290 surrounding liver, p<0.0001)). However, no significant differences were found concerning Ri, WiAuC, mTT and TTP.

Conclusion

CEUS with color- coded perfusion imaging is a valuable supporting tool for post-interventional success control following TACE of liver lesions. Peak enhancement seems to be the most valuable parameter.

Long-term survival after percutaneous irreversible electroporation of inoperable colorectal liver metastases

Background

For colorectal liver metastases (CRLM) that are not amenable to surgery or thermal ablation, irreversible electroporation (IRE) is a novel local treatment modality and additional option.

Methods

This study is a retrospective long-term follow-up of patients with CRLM who underwent IRE as salvage treatment.

Results

Of the 24 included patients, 18 (75.0%) were male, and the median age was 57 (range: 28-75) years. The mean time elapsed from diagnosis to IRE was 37.9±37.3 months. Mean overall survival was 26.5 months after IRE (range: 2.5-69.2 months) and 58.1 months after diagnosis (range: 14.8-180.1 months). One-, three-, and five-year survival rates after initial diagnosis were 100.0%, 79.2%, and 41.2%; after IRE, the respective survival rates were 79.1%, 25.0%, and 8.3%. There were no statistically significant differences detected in survival after IRE with respect to gender, age, T- or N-stage at the time of diagnosis, size of metastases subject to IRE, number of hepatic lesions, or time elapsed between IRE and diagnosis.

Conclusion

For nonresectable CRLM, long-term survival data emphasize the value of IRE as a new minimally invasive local therapeutic approach in multimodal palliative treatment, which is currently limited to systemic or regional therapies in this setting.

Percutaneous Treatment of Malignant Liver Lesions: Evaluation of Success Using Contrast- Enhanced Ultrasound (CEUS) and Perfusion Software

AIM

 Using new perfusion software for evaluation of the success of percutaneous treatments of malignant liver tumors with CEUS.

MATERIALS AND METHODS

 Retrospective analysis of 88 patients (74 male, 14 female; 30 - 84 years) with 165 malignant liver lesions. The lesions were 57 metastases and 108 HCCs. The success of interventional treatment (IRE n = 47; RFA n = 38; MWA n = 44; TACE n = 36) was evaluated by CEUS and perfusion software (VueBox^®). CEUS was performed after injection of 1 - 2.4 ml of sulfur hexafluoride microbubbles (SonoVue^®) using a 1 - 5 MHz convex probe. DICOM loops up to 1 min. in the ablation area were stored digitally in the PACS. Regions of interest (ROI) were manually placed in the center, the margins of the lesions as well as in the surrounding tissue. Using VueBox^® peak, time to peak (TTP), mean transit time (mTT), rise time (RT), the wash-in and wash-out rate were calculated for the regions, in order to evaluate the success of the percutaneous treatment after the ablation in comparison to the ceCT/ceMRI up to 6 months after the treatment.

RESULTS

 There were significant differences in all cases between the center compared to the margins for the main perfusion parameters (peak, mTT, RT) (p < 0.001). Peak, wash-in and wash-out ratios were further analyzed with the type of lesion and the method of ablation. All parameters were significantly different between lesions treated successfully vs. lesions with recurrence.

CONCLUSION

 A combination of CEUS with perfusion imaging enables critical assessment of successful treatment after percutaneous interventional procedures for a malignant liver lesion.

Evaluation of integrated color-coded perfusion analysis for contrast-enhanced ultrasound (CEUS) after percutaneous interventions for malignant liver lesions: First results

BACKGROUND

 With the rising number of percutaneous ablation therapies in malignant liver lesions there is a need of reliable diagnostics after the intervention to differentiate between reactive changes and tumor.

PURPOSE

To assess the success of percutaneous ablation therapies for malignant liver lesions using CEUS with perfusion analysis.

MATERIAL AND METHODS

Retrospective analysis of perfusion analysis for 67 patients with 94 malignant liver lesions, treated with ablation therapies. The lesions were 70 hepatocellular carcinomas (HCC), 18 metastases, 4 cholangiocellular carcinomas (CCC), 2 lesions remained unclear. CEUS was performed after bolus injection of 1.6-2.4 ml of sulfur-hexafluoride microbubbles. The perfusion analysis was calculated using Peak, TTP, mTT and AUC with integrated software during the late arterial to early portal-venous phase for approximately 9 sec (5-15 sec). For the evaluation of the success after percutaneous treatment the perfusion results were compared to the follow-up control after 6 months with CT and MRI and CEUS.

RESULTS

Perfusion analyses after percutaneous treatment of malignant liver lesions showed highly significant perfusion differences when comparing the center to the surrounding tissue and the margins (p<0.0001) for Peak and also for AUC. 62 lesions were successfully treated, meaning there was no local recurrence after 6 months. In cases of residual tumor CEUS showed a nodular marginal enhancement, the corresponding perfusion analyses showed nodular red and yellow pseudo-color shades.

CONCLUSIONS

Using CEUS and perfusion analysis, a critical analysis of post-ablation defects in malignant liver lesions is possible. With the help of pseudo-colors, remaining tumor-vascularization can be detected.

Evaluation of dynamic effects of therapy-induced changes in microcirculation after percutaneous treatment of vascular malformations using contrast-enhanced ultrasound (CEUS) and time intensity curve (TIC) analyses

The aim of this follow-up study was to demonstrate the effect of percutaneous interventional treatment on local microcirculation of peripheral vascular malformations using CEUS and TIC analysis.

MATERIAL AND METHODS

Retrospective analysis of 197 patients (136 female; 61 male; 3-86 years) with 135 venous (VM), 39 arterio-venous (AVM), 8 lymphatic and 15 veno-lymphatic peripheral vascular malformations before and after the first percutaneous treatment.CEUS was performed after i.v. injection of 1-2.4 ml of sulfur hexafluoride microbubbles (SonoVue®) using a 6-9 MHz linear probe. Digitally stored cine loops (starting in the early arterial phase for 60 sec) were read by independent readers in consensus. Regions of interest (ROI) were defined in the center and at the margins of the malformation, as well as in the healthy surrounding tissue. TIC analyses with Time to Peak (TTP) and Area under the Curve (AUC) were calculated using integrated perfusion software.

RESULTS

After the treatment there was a significant decrease for median AUC in VM in the center from 297.8 (14.5-2167.6) rU down to 243.3 (0.1-1678.8) rU (p = 0.043) and in the surrounding tissue down to 107.7 (20.2-660.2) rU (p = 0.018). For the other malformations AUC decreased in the center and the margins as well. TTP rose, however these changes did not reach the level of significance.

CONCLUSION

Analyzing the capillary microcirculation TICs offer a possibility of monitoring therapy-induced capillary changes of vascular malformations.

Reduced microperfusion due to portal vein thrombosis: Impact on the outcome of percutaneous thermal tumor ablation

PURPOSE

To determine the influence of pre-interventionally existing portal vein thrombosis on the ablation success of percutaneous tumor ablation of HCC.

MATERIALS AND METHODS

15 patients with HCC and pre-existing portal vein thrombosis underwent thermal tumor ablation. We retrospectively analyzed the pre- and post-interventionally performed CT and MRI scans in terms of technical success as well as the complication rate. The portal vein thrombosis was classified into segmental, lobar and central thrombus.

RESULTS

In 13/15 cases (87%) complete ablation with no evidence of residual tumor tissue was seen 6 weeks after the procedure in contrast-enhanced MRI scans and contrast-enhanced ultrasound (CEUS). No major and 2 minor complications were observed after the ablation procedure.

CONCLUSION

Reduced perfusion due to pre-interventionally existing portal vein thrombosis has no significant impact on the ablation success or the complication rate.

Characterization of Focal Liver Lesions using CEUS and MRI with Liver-Specific Contrast Media: Experience of a Single Radiologic Center

AIM

 The purpose of this study was to compare contrast-enhanced ultrasound (CEUS), magnetic resonance imaging (MRI) using liver-specific contrast agent and a combination of both for the characterization of focal liver lesions (FLL).

METHODS

 83 patients with both benign and malignant liver lesions were examined using CEUS and MRI after the intravenous administration of liver-specific contrast media. All patients had inconclusive results from prior imaging examinations. Histopathological specimens could be obtained in 53 patients. Ultrasound was performed using a multi-frequency curved probe (1 - 6 MHz) after the injection of 1 - 2.4 ml ultrasound contrast media. The sensitivity, specificity, positive predictive value and negative predictive value of CEUS, MRI and a combination of both (CEUS + MRI) were compared.

RESULTS

 The sensitivity, specificity, positive and negative predictive values regarding lesion classification were 90.9 %, 70.6 %, 92.3 % and 66.6 %, respectively, for CEUS; 90.9 %, 82.4 %, 95.2 % and 70.0 %, respectively, for MRI; and 96.9 %, 70.6 %, 92.7 % and 85.7 % respectively, for CEUS + MRI. There were no statistically significant differences. 6 malignant lesions were missed using CEUS or MRI alone (false negatives). The use of both modalities combined reduced the false-negative results to 2.

CONCLUSION

 CEUS and MRI with liver-specific contrast media are very reliable and of equal informative value in the characterization of focal liver lesions. The number of false-negative results can be decreased using a combination of the two methods.

Analysis of Liver Tumors Using Preoperative and Intraoperative Contrast-Enhanced Ultrasound (CEUS/IOCEUS) by Radiologists in Comparison to Magnetic Resonance Imaging and Histopathology

Purpose To evaluate the diagnostic significance of preoperatively and intraoperatively performed contrast-enhanced ultrasound (CEUS/IOCEUS) in the diagnosis of liver tumors in comparison to magnetic resonance imaging (MRI) and histopathology. Materials and Methods Retrospective analysis of 70/317 patients who underwent surgery for liver tumors between January 2012 and October 2015. Findings of CEUS and IOCEUS were compared to MRI. CEUS and IOCEUS were performed using multifrequency linear probes (1 - 5, 6 - 15 MHz) after bolus injection of 1 - 5 ml sulfur hexafluoride microbubbles. The histopathology after surgical resection, MRI morphology (T1, T2, VIBE, diffusion sequences) and wash-in/wash-out kinetics of CEUS were evaluated. Results In 70 analyzed patient cases, 64 malignant liver lesions could be detected. 6 patients had benign liver lesions. Among the 64 malignant lesions, there were 28 metastases, 24 hepatocellular carcinomas (HCC), 9 cholangiocellular carcinomas (CCC) and 3 gallbladder carcinomas. 2 of the 6 benign liver lesions were hemangiomas, 2 were adenomas, 1 was an FNH and 1 was a complicated cyst. There was no significant difference when determining the lesion's malignancy/ benignity (p = 1.000). Furthermore, there was no statistical significance between preoperative CEUS and MRI regarding the general differential diagnosis of a tumor (p = 0.210) and the differential diagnosis classification between HCCs (p = 0.453) and metastases (p = 0.250). There was no statistical significance in tumor size (10 mm - 151 mm; mean 49 mm SD +/- 31 mm) and location (tumor size p = 0.579; allocation to liver lobes p = 0.132; segment diagnosis p = 0.121) between preoperatively performed CEUS and MRI. The combination of preoperative MRI and CEUS for lesion detection showed significant differences compared to CEUS or MRI only (p < 0.001 for CEUS; p = 0.004 for MRI). IOCEUS offered the substantial advantage of locating additional liver lesions (p = 0.004 compared to preoperative MRI, p = 0.002 compared to preoperative CEUS). In 10/37 cases (27 %) IOCEUS could locate further liver lesions which had not been identified during CEUS and/or MRI preoperatively, so that operative therapy was adapted accordingly and resection was extended if necessary. Conclusion CEUS proves to be a dynamic imaging method for preoperative diagnosis of liver tumors showing high diagnostic significance in the characterization of a tumor's microvascularization, its entity and its size. During liver operations CEUS plays an important role in surgical therapy decisions. Citation Format · Huf S, Platz Batista da Silva N, Wiesinger I et al. Analyse von Lebertumorentitäten mittels präoperativer und intraoperativer Kontrastmittelsonografie (CEUS/IOCEUS) durch Radiologen im Vergleich zur Magnetresonanztomografie und zur Histopathologie. Fortschr Röntgenstr 2017; 189: 431 - 440.

Analysis of arterial dynamic micro-vascularization with contrast-enhanced ultrasound (CEUS) in thyroid lesions using external perfusion software: First results

AIM

To determine different perfusion characteristics of histo-pathologically proven adenomas and carcinomas of the thyroid gland with CEUS and perfusion software.

MATERIAL AND METHODS

Retrospective perfusion analysis of 25 patients with carcinomas and 41 cases of adenomas of the thyroid gland (30 males, 36 females; aged 18 - 85 years, mean 56 years). All cases were histologically analyzed. Perfusion analysis was independently performed using external perfusion software (VueBox®). TTP, mTT, Peak and Rise time were calculated.

RESULTS

Lesions' sizes ranged from 0.2 to 10.2 cm in carcinomas (mean 2.18 cm), and from 0.6 to 5.0 cm in adenomas (mean 2.25 cm). In 20 out of 25 carcinomas that were evaluated with CEUS, a complete wash-out in the late venous phase was found. Adenomas showed wash-out at the border.Perfusion analysis in VueBox® revealed some parameters which tend to show differences between adenomas and carcinomas, however did not reach the level of significance.Median Peak in carcinomas was highest at the margins (2945 rU), and lowest in the surroundings (1110 rU). Mean Transit Time (mTT) values showed no differences between center, margin and surrounding.In adenomas healthy tissue showed higher mTT values compared to the center (24.6 vs. 20.7 sec). Median Peak was highest in the surrounding tissue and lowest in the margins (1999 vs. 1129 rU). No statistical differences could be found in the comparisons.

CONCLUSION

CEUS with perfusion analysis offers new possibilities for the dynamic evaluation of micro-vascularization in thyroid adenomas and carcinomas. Using VueBox® the perfusion analysis of the arterial phase provides new parameters that help determine a lesion's malignancy or benignity. However a final assessment regarding malignancy and benignity of thyroid lesions using only CEUS and perfusion analysis of the arterial phase is not yet possible.

Intrasurgical dignity assessment of hepatic tumors using semi-quantitative strain elastography and contrast-enhanced ultrasound for optimisation of liver tumor surgery

OBJECTIVE

To evaluate the efficacy of strain elastography (SE) using semi-quantitative measurement methods compared to constrast enhanced ultrasound during liver tumor surgery (Io-CEUS) for dignity assessment of focal liver lesions(FLL).

MATERIAL AND METHODS

Prospective data acquisition and retrospective analysis of US data of 100 patients (116 lesions) who underwent liver tumor surgery between 10/2010 and 03/2016. Retrospective reading of SE color patterns was performed establishing groups depending on dominant color (>50% blue = stiff, inhomogenous, >50% yellow/red/green = soft tissue). Semi-quantitative analysis was performed by Q-analysis based on a scale from 0 (soft) to 6 (stiff). 2 ROIs were placed centrally, 5 ROIs in the lesion's surrounding tissue. Io-CEUS was performed by bolus injection of 5-10 ml sulphurhexaflourid microbubbles evaluating wash-in- and -out- kinetics in arterial, portal venous and late phase. Histopathology after surgical resection served as goldstandard.

RESULTS

100 patients (m: 65, f: 35, mean age 60.5 years) with 116 liver lesions were included. Lesion's size ranged from 0.5 to 8.4 cm (mean 2.42 cm SD±1.44 cm). Postoperative histology showed 105 malignant and 11 benign lesions. Semi-quantitative analysis showed central indurations of >2.5 in 76/105 cases suggesting malignancy. 7 benign lesions displayed no central indurations correctly characterized benign by SE. ROC-analysis and Youden index showed a sensitivity of 72.4% and specificity of 63.6% assuming a cut-off of 2.5. Io-CEUS correctly characterized 103/105 as malignant. Sensitivity was 98%, specificity 72.7%.

CONCLUSION

Strain elastography is a valuable tool for non-invasive characterization of FLLs. Semi-quantitative intratumoral stiffness values of >2.5 suggested malignancy. However, sensitivity of Io-CEUS in detecting malignant lesions was higher compared to SE. In conclusion SE should be considered for routine use during intraoperative US in addition to Io-CEUS for optimization of curative liver surgery.

Interventional Removal of Intravascular Medical Devices: Methods and Technical Success

PURPOSE

Evaluation of the technical success rate and complications when retrieving dislocated intravascular foreign bodies.

MATERIAL AND METHODS

Between 1999 and 2015 38 patients (21 female; 17 male; Age: 17 - 92; Average 54.3 years) underwent an extraction of intravascular dislocated foreign bodies, which were not lost during a radiological intervention. The extracted material included 29 port catheters, 3 tips of tunneled dialysis catheters, 2 stents, 2 guide wires, 1 CVC tip and 1 AS occluder device. Various catheters for repositioning and extraction were used. The access was transarterial as well as transvenous. Technical success was defined as complete removal of the foreign body.

RESULTS

The technical success rate was 92.1 % (35 of 38). In 17 patients an additional catheter was necessary to reposition the foreign body in order to make it accessible for the extraction catheter. In one case a stent was relocated and remodeled within the patient and was not extracted. In another case we experienced a dislocation of a small fragment of the port catheter into the distal parts of the pulmonary artery, which couldn't be extracted. A guide wire could not be extracted as it was already adhered with the vessel wall. Peri-interventional complications were not documented.

CONCLUSION

The percutaneous extraction of dislocated intravascular foreign bodies is technically successful and poor of complications. Interventional therapy can avoid surgical removal.

KEY POINTS

• The percutaneous extraction of dislocated intravascular foreign bodies is technically successful and safe.• In most cases surgical removal can be avoided.• The gooseneck-snare catheter was mainly used for the extraction of intravascular foreign bodies. Citation Format: • Ayx I, Goessmann H, Hubauer H et al. Interventional Removal of Intravascular Medical Devices: Methods and Technical Success. Fortschr Röntgenstr 2016; 188: 566 - 573.

Evaluation of the contribution of radiological imaging to the final diagnosis in medical case reports

PURPOSE

To evaluate the clinical value and impact of radiological imaging in published medial case reports.

METHODS

We analysed 671 consecutively published case reports of a peer-reviewed medical journal for case reports. The general use of radiological imaging as well as the specific imaging modality used in each case (ultrasound, x-ray, fluoroscopy, CT, MRI) was documented, and most importantly the 'final problem solver', i.e. the diagnostic modality giving the final clue to the patient's diagnosis, was identified.

RESULTS

In 511 of 671 (76.1 %) analysed case reports at least one radiological modality was used in the diagnostic cascade. In 28.6% of all cases the final diagnosis was achieved by radiological imaging. All other cases were solved by the patient's history and physical examination (15.2%), histology (12.4%), and blood analysis (9.6%). When radiology was the 'final problem solver', it was mainly CT (51.6%) and MRI (30.6%). In 52.2% of the case reports the radiological image was included in the article.

CONCLUSION

In case reports published in a prominent general medical journal radiological imaging is an important key player in the diagnostic process. In many cases, it is also the diagnostic tool which ultimately leads to determining the final diagnosis.

KEY POINTS

• Radiology was the most important specialty for finding the final diagnosis. • CT was the most successful problem-solving imaging modality followed by MRI. • MRI and CT had the best solution rates of more than 30%.