Focal malignant liver lesions: diagnosis by dynamic incremental CT, early phase

The purpose of our study was to evaluate the accuracy of dynamic incremental bolus-enhanced conventional CT (DICT) with intravenous contrast administration, early phase, in the diagnosis of malignancy of focal liver lesions. A total of 122 lesions were selected in 74 patients considering the following criteria: lesion diameter 10 mm or more, number of lesions less than six per study, except in multiple angiomatosis and the existence of a valid criteria of definitive diagnosis. Lesions were categorized into seven levels of diagnostic confidence of malignancy compared with the definitive diagnosis for acquisition of a receiver-operator-characteristic (ROC) curve analysis and to determine the sensitivity and specificity of the technique. Forty-six and 70 lesions were correctly diagnosed as malignant and benign, respectively; there were 2 false-positive and 4 false-negative diagnoses of malignancy and the sensitivity and specificity obtained were 92 and 97 %. The DICT early phase was confirmed as a highly accurate method in the characterization and diagnosis of malignancy of focal liver lesions, requiring an optimal technical performance and judicious analysis of existing semiological data. Correspondence to: R. M. Marques     

Size of gas-filled bowel loops in infants

Percutaneous fine-needle aspiration biopsy of focal liver lesions was performed in 36 patients. Of the biopsies, 83% yielded enough cytologic material for a correct diagnosis, without significant complications. The primary indication for the biopsy was to document the presence of malignancy and avoid a diagnostic laparotomy.     

CT-guided biopsy of thoracic mass lesions followed by fast stain technique]

We performed CT-guided needle biopsy of 92 thoracic mass lesions using a Rotex-II screw needle. Fast stain technique was performed for an immediate evaluation of the specimen in the last 39 procedures. The overall accuracy of malignancy was 93.2%, and the correct histological typing was obtained in 82.8% of malignancy proven at surgery or autopsy. The method enabled histopathological diagnosis of thoracic lesions, which could not obtained by other diagnostic modalities including fiberoptic bronchoscopy or fluoroscopy-guided biopsy. The true positive rate increased up 10.2% to 91.3% by introducing fast stain technique. A close cooperation between radiologists and cytopathologists was essential for performing this CT-guided biopsy procedure followed by fast stain technique.     

US-guided percutaneous liver biopsy with plugging of the needle track: a prospective study in 72 high-risk patients.

The efficiency, accuracy, and safety of ultrasound-guided liver biopsy with plugging of the needle track were prospectively assessed in 72 patients at high risk for hemorrhage. Seventy-eight biopsy procedures were performed in 72 consecutive patients prospectively classified into four different groups on the basis of coagulation parameters. Sixty-two patients (86%) had severe or moderately severe coagulation disorders. Fifty-four biopsy procedures were performed in 50 patients with diffuse liver disease, and 24 were performed in 24 patients with focal liver lesions. The biopsy track was embolized with gelatin particles and thrombin. Biopsy specimens adequate for histologic diagnosis were obtained in 69 of the 72 patients (96%). In focal lesions, accuracy and sensitivity in the diagnosis of malignancy were 75% and 89%, respectively. Two serious bleeding complications (2.8%) were encountered in two of the patients with major coagulation disorders. Liver biopsy with plugging of the needle track is a practical technique and is a feasible alternative to the transjugular approach. Respective indications for both methods depend on the severity of coagulation disorders and the presence of focal lesions.     

Nuclear medicine and ultrasound: Correlation in diagnosis of disease of liver and biliary tract

Even though the radiocolloid scan is nonspecific it will be approximately 70%-80% accurate in predicting the presence or absence of liver disease and somewhat less accurate than that in making statements as to the specific type of disease. This compares well with other modalities. The ability of nuclear medicine techniques to provide a correct diagnosis is improved when additional isotopic techniques such as hepatic blood flow studies and 131I-rose bengal and 67Ga scanning are performed. Ultrasound scanning is also non specific. To date, the major application of ultrasound in the study of the liver has been in deciphering puzzling contour abnormalities seen on nuclear medicine scans and in demonstrating fluid-filled abnormalities. Its usefulness in diffuse and solid focal lesions has been less dramatic. More recently, however, the development of gray scale has necessitated a reevaluation of the technique. Gray scale demonstrates a large number of intrahepatic interfaces that were previously invisible, and it has already been shown to demonstrate focal disorders such as metastasis more easily than the nongray-scale method. It can also demonstrate dilated biliary radicals, the gallbladder, and gallstones. In addition, while routinely studying the liver one can evaluate diaphragmatic motion and various retroperitoneal structures such as the pancreas, lymph nodes, and abdominal vascular structures.     

Ultrasound-guided percutaneous needle biopsy in hepatic lesions suspected of hepatocarcinoma. Evaluation of 104 patients]

The use of US in both everyday routine and regular follow-up of patients affected with chronic hepatopathies makes it possible to detect even very small focal liver lesions. However, in many cases, neither US nor any other imaging method is sufficient for tissue characterization, and biopsy becomes thus indispensable to establish the diagnosis of hepatocellular carcinoma (HCC). The authors report the results of the US-guided biopsies with fine aspirating and cutting needles (FNAB) performed in 104 patients affected with focal liver lesions suspected for HCC. Smear cytology detected 67/83 proven HCCs: in 4 patients it showed a kind of malignancy which could not be typified; the patterns suggestive of HCC were 2, the false negatives were 7 and the inadequates 3. Microhistology, which was performed in 81 patients, allowed HCC to be diagnosed in 56 cases; a diagnosis of generic malignancy was made in 2 patients. There were 9 true negatives, 6 false negative, and 8 inadequates. Thanks to the combination of the two methods, 77 HCCs were diagnosed, with 92.8% typyfying accuracy; the false negatives were 4 and the inadequates 2. Typifying accuracy reached 95.8% in the group of 72 patients, all affected with HCC, in which both investigations were performed; there were 2 false negatives and 1 inadequate. These results confirm the value of US-guided FNAB in the diagnosis of HCC and the complementary role of smear cytology and microhistology: the combined use of the latter methods allows both false-negative and inadequate findings to be markedly reduced.     

Percutaneous image-guided cutting-needle biopsy of the pleura in the presence of a suspected malignant effusion

PURPOSE: To evaluate the diagnostic accuracy of percutaneous image-guided cutting-needle biopsy of pleural thickening in the presence of a suspected malignant pleural effusion. MATERIALS AND METHODS: Thirty-three adult patients with diffuse or focal pleural thickening (median, 1.0 cm; range, 0.2-6.0 cm), pleural effusion, and suspected pleural malignancy underwent percutaneous image-guided cutting-needle biopsy. Biopsy guidance was performed with computed tomography in 24 patients and ultrasonography in nine patients. A final diagnosis of benign or malignant disease was established with radiologic and clinical follow-up findings and with other histologic or cytologic findings, when available. RESULTS: A correct histologic diagnosis of malignant disease was made in 21 of 24 patients (sensitivity, 88%; specificity, 100%), including 13 of 14 patients with mesothelioma (sensitivity, 93%). A correct histologic diagnosis of benign pleural disease was made in nine patients. Positive and negative predictive values for malignant disease were 100% and 75%, respectively. The overall accuracy was 91%. Complications comprised a chest wall hematoma in one patient. CONCLUSION: Image-guided percutaneous cutting-needle biopsy of pleural thickening in the presence of a pleural effusion is a safe procedure, with an overall accuracy of 91% in the diagnosis of malignancy.     

Value of heparinized fine-needle aspiration biopsy in liver malignancy

The accuracy of diagnosis of hepatic malignancy by percutaneous aspiration biopsy was compared using heparinized and nonheparinized 22-gauge needles. When a heparinized instrument was used, it was able to accurately diagnose malignancy and cytologic types of exfoliative cells. Heparinization also made it possible to recover small tissue fragments and make ultrathin sections for histologic examination. In this way, material suitable for cytologic and histologic examination was obtained from 100% and 95%, respectively, of 59 patients suspected of having hepatic malignancy. A correct diagnosis was made cytologically in 92.5% of patients with hepatic malignancy and in 89.5% of those from whom histologic material was obtained. From a combination of histologic and cytologic results, the overall diagnostic rate for hepatic malignancy was increased to 95%. This procedure proved to be a reliable method for diagnosis of hepatic malignancy.     

实时超声造影在肝脏局灶性病变诊断中的应用

目的:评价实时超声造影技术在肝脏局灶性病变诊断中的作用及意义.方法:采用实时超声造影技术,对我院269例肝脏局灶性病变进行超声造影检查.结果:92.4%恶性病变动脉相呈现回声增强.病灶动脉相呈现高增强或等增强、延迟相消退为低增强或无增强,在良性病变中占13.8%(19/138),恶性病变中为94.7%(124/131);实时超声造影诊断肝脏局限性病灶的敏感度89.6%,特异度97.5%,诊断符合率93.2%.结论:实时超声造影可显示肝局灶性病变的血流灌注特点,对肝局灶性病变的分类诊断有重要的应用价值.     

肝脏局灶性病变MR动态增强扫描及临床意义

目的探讨肝脏局灶性病变ＭＲ动态增强扫描方法及临床意义。方法作者前瞻性研究了１３６例肝脏局灶性病变，包括肝细胞性肝癌、周围型肝内胆管细胞性肝癌、转移瘤及海绵状血管瘤。采用平静呼吸状态下梯度回波Ｋ空间中心部分采集技术、７个连续层面８个时相动态增强扫描。结果各例均动态增强扫描成功。动态扫描显示时间信号强度曲线在肝细胞性肝癌呈速升速降型；胆管细胞癌呈渐升型；转移瘤呈环形强化，缓慢升高型；海绵状血管瘤呈速升平台型。结论平静呼吸下Ｋ空间中心部分采集肝脏动态扫描，可以显示肝脏局灶病变的血供状态，而且不同病变具有不同的强化特征。     

Dynamic CT of hepatic masses with intravenous and intraarterial contrast material

Seven patients with primary and metastatic hepatic tumors had dynamic computed tomographic scans obtained after an intravenous and an intrahepatic arterial bolus of contrast media. Four patients had hepatoma and three had hepatic metastasis from either a colonic, pancreatic, or leiomyosarcoma primary malignancy. Computed tomography was also performed after an intravenous drip infusion of contrast material. Time-density curves of the hepatic lesions after contrast administration were analyzed and compared. The results demonstrated that: (1) intrahepatic arterial delivery of contrast fluid resulted in the greatest contrast enhancement of lesions and detected more lesions than the intravenous bolus technique, which was superior to the drip infusion technique; (2) no consistent difference in the pattern of contrast enhancement was found between various hepatic lesions; (3) within multiple lesions of similar pathology in any one liver, a spectrum of contrast enhancement pattern was found; and (4) changes in contrast enhancement occurred rapidly and lesions changed from hypodense to isodense to hyperdense to isodense within 30--45 sec.     

US-guided transthoracic cutting biopsy for peripheral thoracic lesions less than 3 cm in diameter

PURPOSE: To evaluate the safety and accuracy of ultrasonography (US)-guided transthoracic cutting biopsy for diagnosing peripheral thoracic lesions (<3 cm). MATERIALS AND METHODS: Fifty consecutive patients with peripheral thoracic lesions less than 3 cm in diameter underwent US-guided percutaneous transthoracic cutting biopsy with a modified technique. Fifty lesions (43 parenchymal lung, two pleural, two chest wall, and three anterior mediastinal lesions) were sampled for biopsy. The final diagnosis was based on histopathologic analysis of surgical specimens (n = 18) or clinical follow-up (n = 32). RESULTS: The histology recovery rate was 98% (49 lesions), and the correct diagnosis was obtained in 48 lesions (96%). Twenty-four (48%) lesions were malignant, and 26 (52%) were benign. The diagnostic accuracy for malignant lesions was 92% (22 of 24 lesions). A specific benign diagnosis was made in 17 (65%) of the 26 benign lesions, and the negative predictive value for malignancy was 93% (26 of 28 lesions). Only two patients (4%) developed postbiopsy pneumothorax, and three (6%) developed postbiopsy hemoptysis. Biopsy helped prevent surgery or thoracoscopy in 32 patients (64%): 18 patients with benign disease and 14 with multiple metastases or inoperable cancer. CONCLUSION: US-guided transthoracic cutting biopsy appears to be a safe and effective method for diagnosing peripheral thoracic lesions less than 3 cm in diameter. The high diagnostic accuracy for benign lesions and metastatic lung cancer can help prevent surgery in many cases.     

Stereotaxic localisation and aspiration cytology of impalpable breast lesions

As part of a programme of assessment of the 'Sterotix' localisation device, aspiration cytology was carried out on 50 patients with 52 impalpable, mammographically detected breast lesions using the stereotaxic guidance device. This was followed by an open localisation biopsy of the area for confirmation. In 12 patients (23%) the aspirations failed to yield sufficient material for diagnosis. This was frequently due to the poorly cellular nature or very small size of the lesions. Of the remaining 40 patients, 15 were regarded as having both mammographically and cytologically benign changes which were confirmed histologically; they could thus have been spared diagnostic surgery. Ten patients had a diagnosis of malignancy with both investigations, and could have had planned investigation and subsequent definitive surgery. Of the remainder, 14 lesions had a report of malignancy or suspicion of it with either technique and these patients would have come to conventional localisation biopsy. Only one patient was found to have a malignancy, who had cytologically benign and mammographically 'probably benign' disease: this was an invasive lobular carcinoma with a dominant in-situ component and may well have been an incidental finding on biopsy.     

Touch-preparation cytologic examination of breast core biopsy specimens: Accuracy in predicting benign or malignant core histologic results

RATIONALE AND OBJECTIVES: The purpose of this study was to determine the accuracy of touch-preparation cytologic examination of breast core biopsy specimens in predicting benign or malignant core histologic results. MATERIALS AND METHODS: One hundred two core biopsies were performed on 88 women with stereotactic or ultrasonographic (US) guidance. Slides were prepared by smearing one core sample on each slide, spraying the slides with fixative, and staining them with the Papanicolaou technique. Slides were blindly reviewed by a cytopathologist. Cytologic results were categorized as positive for malignancy, not diagnostic for malignancy, or insufficient for diagnosis. Results were correlated with histologic results from all specimens obtained during the core biopsy. RESULTS: Imaging depicted the lesions sampled for biopsy as masses (n = 70), clustered calcifications (n = 29), focal asymmetries (n = 2), or architectural distortion (n = 1). Touch-preparation slides of 87 (85%) lesions contained sufficient material for diagnosis. Cytologic results correctly identified 12 of 16 (three of five intraductal and nine of 11 invasive) malignancies in 10 of 13 masses and two of three clusters of calcifications. Two false-positive results occurred, both with fibroadenomas. Overall, touch-preparation studies produced 69 true-negative and four false-negative results. Excluding slides with insufficient material, the sensitivity, specificity, and accuracy of touch-preparation results were 75%, 97%, and 93%, respectively. Including insufficient samples, accuracy was 79%. CONCLUSION: Although touch-preparation cytologic examination of breast core biopsy specimens is fairly accurate in prediction of benign or malignant core histologic results, its correlation with histologic results is not sufficient to justify routine use in immediate counseling and treatment planning.     

Transthoracic aspiration biopsy of pulmonary and mediastinal lesions

Thoracic aspiration biopsy (TAB) constitutes a useful technique in establishing a diagnosis in diseases of the lungs and mediastinum. Results obtained from 1046 fluoroscopically-guided TABs are presented with review of the most important aspects of the technique. Diagnostic accuracy in malignancy detection was 93.8% in lung lesions (n = 984) and 74.5% in mediastinal lesions (n = 62). Sensitivity was higher in peripheral than in central lesions (96% vs. 87%, respectively). Specificity was 100% in both groups. Sensitivity in lesions smaller than 2 cm was 70% and 94% in larger lesions. Aspiration biopsies performed with Chiba and Franseen needles showed a similar sensitivity (95%) higher than with other types of needles. A pneumothorax developed in 138 patients (13.2%). Only eight of these required the use of an endothoracic tube (0.8% of all biopsies).     

Histological sampling with a 23 gauge modified Menghini needle

A 23 gauge modified Menghini (Surecut) needle biopsy technique for obtaining tissue core biopsies was compared with the conventional fine needle aspiration biopsy technique in the diagnosis of ultrasonically detected abdominal mass lesions. In 30 consecutive cases (19 malignant and 11 benign), adequate material for histological examination was obtained in 87% and for cytological examination in 97%. The diagnostic accuracy with respect to malignancy was 84% for histology and 89% for cytology. The predictive value of malignancy was 100% in both. The histological material provided additional information in four cases of malignancy, concerning the type and origin of the tumours, and in nine cases of benign lesions, indicating the type of lesion that appeared as a tumourlike mass in the ultrasound study. The Surecut needle biopsy has been found valuable in obtaining histological material from abdominal mass lesions and may supplement or even replace the fine needle aspiration biopsy in such lesions.     

Value of CT guided renal biopsies: retrospective review of 67 cases

PURPOSE: To assess the value of the CT guided percutaneous biopsy of renal tumors and to promote the interest of this procedure. MATERIAL AND METHODS: We report a retrospective study of 67 patients (average age, 51 years) who underwent CT guided biopsy of a single renal mass. The average size of tumors was 5 centimeters. The biopsy of tumors was carried out with needles between 16 and 21 gauge by using a conventional CT. Two to three passes per tumor were obtained. RESULTS: Biopsy material was sufficient for diagnosis in 48 cases (72%). A renal cell carcinoma was found in 29 (43%) samples of biopsy. The remainder included 13 metastases or lymphomas (18%). A benign lesion was found in 6 cases (9%). 59 patients had a final diagnosis. Accuracy of the biopsy for histopathologic evaluation was 81%. The average lesion size of failed biopsies was 1.5 centimeters. Morbidity occurred in 13% of cases, without immediate life threatening consequence. CONCLUSION: CT-guided renal biopsy is an effective means of obtaining tissue for the diagnosis of focal renal masses. The indications are renal lesions locally advanced, multimetastatic patients, mass in patients with a single kidney and focal lesions in patients with prior history of malignancy.     

Comparison of CT and fiberoptic bronchoscopy in the evaluation of bronchial disease

CT was compared to fiberoptic bronchoscopy in a large series of patients to study the value of CT for visualizing bronchial disease. CT scans were available for review in 64 cases in which focal airway disease was identified with fiberoptic bronchoscopy and in 38 patients in whom the airways appeared normal at bronchoscopy. CT was positive in 59 of 64 cases in which lesions were detected endoscopically. If the results are analyzed according to the extent of involvement of individual bronchi, CT successfully identified 88 (90%) of 98 lesions. CT correctly excluded disease in 35 (92%) of 38 cases that were subsequently verified to be normal by fiberoptic bronchoscopy. In no case was the diagnosis of malignancy missed by CT. While extremely accurate in detecting focal lesions, CT was inaccurate in predicting whether a given abnormality was endobronchial, submucosal, or extrinsic (peribronchial). In three cases CT failed to detect submucosal extension into the left mainstream bronchus, which has important implications concerning the value of CT in staging bronchial malignancy. It is concluded that CT is helpful when bronchoscopy is contraindicated or refused. CT may also be used in selected cases when there is low clinical suspicion of endobronchial disease and as a complementary procedure to fiberoptic bronchoscopy for outlining the exact location of major mediastinal and hilar vessels, lymph nodes, and tumor in relation to adjacent airways.     

Dilatation of the intrahepatic bile ducts associated with benign liver lesions: an unusual finding

In three patients presenting different types of liver lesions, including isolated cyst, focal nodular hyperplasia (FNH), and hemangioma, intrahepatic bile duct dilatation was observed on US and CT. Final diagnosis was obtained by surgery in two cases (cyst and FNH) and by 1-year follow-up in one patient presenting an isolated hemangioma. The only common characteristic in our three cases was that lesions were present in segment four according to Couinaud's classification, at the level of the transverse fissure, suggesting that a space-occupying lesion at this site may cause compression of the common hepatic duct and right or left intrahepatic bile ducts. Our report indicates that compression may occur even with lesion of moderate size (35–40 mm in diameter). A benign liver lesion may cause a bile duct dilatation, particularly if located in segment 4, close to the hilum. Awareness of this possibility is important to avoid unnecessary invasive diagnostic procedures, particularly when all imaging criteria are consistent with a benign lesion. Electronic Publication     

Classification of hypervascularized lesions in CE MR imaging of the breast

The purpose of this paper is to define and evaluate a classification category for contrast-enhanced (CE) MR imaging of the breast based on the BI-RADS mammographic categories of the American College of Radiology. Using five evaluation criteria for MR findings (initial signal increase, post-initial signal behavior, shape, border, and contrast material distribution within enhancing tumors) 522 patients (1031 breasts) were analyzed. Scores were given from 0 to 8 points and classified into five categories (group I: 0 points, negative; group II: 1-2 points, benign; group III: 3 points, probably benign; group IV: 4-5 points, suspicious abnormality; group V: 6-8 points, highly suspicious for malignancy) to 265 focal hypervascularized breast lesions in 244 breasts (patient group A). These findings were correlated with histology or follow-up. Additionally, this classification was correlated to the contrast medium uptake within the parenchyma of the remaining 787 breasts without any focal lesion (patient group B). Two hundred sixty-five hypervascularized lesions in 238 patients (244 breasts, patient group A) were classified into group I: 0%; group II: 27.3%; group III: 22.3%; group IV: 18.6%; and group V: 31.8%. Histology revealed 115 benign and 134 malignant tumors in these groups. Sixteen benign lesions were controlled by follow-up. Sensitivity for the detection of malignancy using the presented multifactorial MRM classification was 92%, and specificity was 92%. Excluding cases of ductal carcinoma in situ specificity increased to 95%. Seven hundred eighty-seven breasts without any focal hypervascularized lesion (patient group B) were classified into groups I or II. Follow-up ( n=771) or histology ( n=14) confirmed the diagnosis in 785 of these breasts. Histopathology revealed, however, malignant tumors in the remaining two cases. The classification of lesions based on a multifactorial analysis is very helpful in the interpretation of CE MRI of the breast. The evaluation of all diagnostic imaging modalities, however, is essential in determining the correct diagnosis and/or in deciding on the appropriate therapeutic procedure.