Multicentric occurrence of hepatocellular carcinoma: In terms of pathology study

The remarkable advances in diagnostic techniques and in the pathomorphologic study of minute hepatocellular carcinomas (HCCs) in the early stage indicate that many HCCs are multicentric in origin. Morphologically, combinations of HCC nodules and other nodules, such as adenomatous hyperplasia containing cancerous foci, well-differentiated HCC, or well-differentiated HCC containing moderate or poorly differentiated cancerous tissue are considered to originate and proliferate in situ. These combinations are considered to be HCC of synchronous multicentric origin. We found that, in HCC associated with liver cirrhosis, 6 of 74 consecutively resected HCCs (8.3%) and 4 of 8 autopsy cases (50%) satisfied the above criteria for multicentric origin. This discrepancy between surgical and autopsy cases can be explained thus: In surgical cases, morphologic examination is limited to only the vicinity of the main tumor and patients with multiple minute tumors HCC tend not to be sent to the operation table. Thus, the frequency seen in autopsy cases may reflect the true figures for multicentric origin. In 94 HCCs associated with chronic hepatitis, we found none showing coexistence of the above nodules that are suggestive of synchronous multicentric origin.     

声辐射力脉冲弹性成像对甲状腺良恶性结节的鉴别诊断价值

目的探讨声辐射力脉冲（acoustic radiation force impulse,ARFI）的声触诊组织定量（virtual touch tissue quantification,VTQ）技术鉴别诊断甲状腺良恶性结节的价值。方法对63个甲状腺结节行常规超声检查,并采用超声弹性成像（EI）技术对病灶组织进行EI分级,采用VTQ技术检测病灶组织的剪切波速度（shear wave velocity,SWV）。以术后病理学检查结果作为金标准,采用受试者工作特征曲线（ROC曲线）评估常规超声、EI及VTQ技术诊断甲状腺结节性质的最佳诊断界点及诊断价值。结果 63个甲状腺结节中有良性结节45个,恶性结节18个。常规超声检查、EI及VTQ技术的受试者工作特征（ROC）曲线下面积分别为0.837（95%CI：0.712～0.962）、0.863（95%CI：0.751～0.974）及0.900（95%CI：0.810～0.990）,与0.5比较差异均有统计学意义（P=0.001）,但三者间曲线下面积比较差异无统计学意义（P〉0.05）。常规超声检查的最佳诊断界点为具有3项恶性表现,相应的灵敏度、特异度及准确率分别为83.3%,86.7%及85.7%。EI的最佳诊断界点为Ⅳ级,相应的灵敏度、特异度及准确率分别为94.1%、82.6%及87.3%。VTQ技术的最佳诊断界点为3.39 m/s,相应的灵敏度、特异度及准确率分别为88.9%,91.1%及90.5%。结论常规超声检查、EI及ARFI的VTQ技术对甲状腺实性结节的良恶性鉴别诊断均有诊断价值,在鉴别诊断时需相互结合,综合考虑。     

甲状腺结节的诊断评价

随着诊断技术的和健康体检的普及,甲状腺结节的检出率逐年增高,对于结节的诊断评价决定着该结节是否需要治疗甚至手术,正确的诊断评价可以使恶性结节及时得到治疗、良性结节免予手术,合理利用有限的医疗资源.本文对近年甲状腺结节的诊断评价作一简要综述.     

Cytologic evaluation of solitary thyroid nodules

Fine-needle aspiration is a low-cost diagnostic tool with principal value in determining which patients with thyroid nodules should undergo surgery. Team work and close cooperation among endocrinologists, surgeons, and pathologists are essential for success. Cytologic criteria for diagnosis of the most frequent conditions (benign cystic lesions), Hashimoto thyroiditis and malignancies found in thyroid aspirates have been provided. The unsolved problem of the so-called "follicular" or oxyphilic lesion or neoplasia will be investigated by immunocytochemistry.     

Percutaneous Needle Biopsy of the Lung and Its Impact on Patient Management

Percutaneous needle biopsy (PNB) of the lung is a commonly performed procedure, mainly used for the investigation of solitary pulmonary nodules. Developments in imaging, particularly computed tomography (CT), have enable accurate preliminary assessment and targeting of lesions. Improvements in needle design ensure the provision of diagnostic samples for both cytologic and histologic assessment; and the development of immunocytochemistry and immunohistochemistry have allowed improved accuracy in diagnosis. A significant improvement in diagnostic accuracy for benign lesions has been associated with the use of cutting needles that provide cores for histologic diagnosis, in contrast to cytologic analysis from fine-needle aspiration. The complications of PNB are well recorded and have not changed significantly with the newer imaging techniques and needles. The preliminary assessment of solitary pulmonary nodules, and the pretest likelihood of malignancy, has improved using contrast-enhanced CT and positron emission tomography; the latter modality is increasingly having a major impact on the investigation of patients with suspected malignancy. The performance of PNB must always be determined on an individual case basis and when the result is likely to affect management. The complementary roles of PNB, bronchoscopic biopsy, and video-assisted thoracoscopic biopsy continue to evolve.     

多排螺旋CT在脂肪肝背景下肝脏结节性疾病诊断中的应用分析

目的探讨多排螺旋CT(MSCT)在脂肪肝背景下鉴别诊断肝脏结节性疾病中的临床价值。方法选取2013年3月至2016年3月经病理确诊的280例脂肪肝合并肝脏结节性疾病患者的影像学资料进行回顾性分析,所有患者均接受了超声、MSCT检查,以病理学结果作为诊断标准,分别计算两种影像学方法鉴别诊断脂肪肝合并肝脏结节性疾病的诊断学价值。数据统计分析采用SPSS 18.0进行处理,计算灵敏度、特异度、漏诊率、误诊率及绘制受试者工作曲线(ROC),计数资料采用%进行描述;组间比较采用χ2检验;P0.05表示差异有统计学意义。结果 280例患者共检出338个结节,经病理诊断其中188例良性患者检出良性结节227个(67.1%),92例恶性患者共检出恶性结节111个(32.8%);MSCT鉴别诊断脂肪肝良恶性结节的灵敏度为90.99%、特异度为91.63%、漏诊率9.01%、误诊率8.37%、ROC曲线下面积AUC值为0.922;超声鉴别诊断脂肪肝良恶性结节的灵敏度为61.26%、特异度为69.60%、漏诊率38.74%、误诊率30.40%、ROC曲线下面积AUC值为0.684。MSCT鉴别诊断脂肪肝良恶性结节的灵敏度、特异度均高于超声(P0.05),漏诊率和误诊率均低于超声(P0.05)。结论 MSCT在脂肪肝背景下鉴别诊断肝脏结节性疾病具有较高的临床价值。     

Thyroid nodules; evaluation of malignancy by ultrasonography

Preoperative ultrasonic examination was correlated to final pathological diagnosis in 102 cases which underwent thyroidectomy in our clinic from 1979 to May 1985. Preoperative ultrasonic diagnosis was as follows: Sensitivity was 78% (45/58 cases), and specificity was 86% (38/44 cases). Four factors in ultrasonic image were considered: Shape, boundary, internal echo and margin were featured, and correlated to malignancy in 75 cases with mainly solid nodules. Among 34 nodules with irregular shape, 33 (97%) were pathologically malignant and 40 of 42 (95%) with rugged boundary were also malignant. Whether internal echo was even or not could not be used as a diagnostic criteria. Similarly, whether a nodule had well defined margin or not was found not to be a significant criteria in order to differentiate malignant from benign lesions. In 15 of 34 cases with lymph node metastases, metastatic lymph nodes were detected by ultrasonography. Lymph node metastases must be also evaluated by ultrasonography preoperatively in thyroid diseases. Each of these factors must be considered individually in the diagnosis of thyroid nodules. By evaluation of the ultrasonography findings the pathological characteristics may be inferred, and consequently being possible to reach a correct diagnosis.     

The role of video-assisted thoracoscopic surgery in the diagnosis of the small peripheral pulmonary nodule

BACKGROUND: The use of imaging techniques to detect small peripheral pulmonary nodules often results in a missed diagnosis. Thoracoscopy had limited application until recently, when advances in technology allowed thoracic surgeons greater visualization and mobility within the chest. METHODS: Between September 1992 and June 1997, 81 patients were treated for small peripheral pulmonary nodules by pulmonary wedge excision using video-assisted thoracoscopic techniques. The patients were 39 men and 42 women with an average age of 59.5 years. RESULTS: A definitive diagnosis was obtained in all cases. Malignancies were found in 44 patients (55%), which involved primary lung cancer in 28 patients and metastatic lesions in 16 patients. The rate of malignancy in nodules measuring 1 cm or less was 18%. There was no operative mortality or morbidity. CONCLUSIONS: We conclude that video-assisted thoracoscopic lung biopsy is a more effective and less invasive diagnostic tool for small peripheral pulmonary nodules.     

Computerized tomography screening for lung cancer: new findings and diagnostic work-up

On computerized tomography (CT) screening for lung cancer within the Early Lung Cancer Action Project, both at baseline and repeat screening, we found not only solid but also subsolid nodules, which unlike solid ones do not completely obscure the lung parenchyma. We established that subsolid nodules represent approximately 20% of the nodules shown on screening and that they have a higher frequency of malignancy than solid nodules. Although we found growth of solid nodules to be a reliable indicator of malignancy, growth of subsolid nodules was more difficult to assess. On review of our results to date in screening, we have continued to refine our definition of a positive result of screening from that given in our initial publication on screening. We have also provided an updated screening regimen. It starts with the initial, low-dose CT test and for all those with positive results on this initial test, the regimen continues by specifying the work-up needed to rule-in a diagnosis of malignancy. In this regimen, we found growth assessed by high-resolution CT to be a useful indicator of malignancy and have developed image-processing tools to help in this assessment. Once growth is ascertained, we recommend fine-needle aspiration for confirmation of malignancy. It may be that once criteria for definitive growth are established and validated, fine-needle aspiration may become optional. However, in the meantime, in the context of screening, a more cautious approach is warranted.     

Clinical diagnosis of ventilator associated pneumonia revisited: comparative validation using immediate post-mortem lung biopsies

BACKGROUND: A study was undertaken to assess the diagnostic value of different clinical criteria and the impact of microbiological testing on the accuracy of clinical diagnosis of suspected ventilator associated pneumonia (VAP). METHODS: Twenty five deceased mechanically ventilated patients were studied prospectively. Immediately after death, multiple bilateral lung biopsy specimens (16 specimens/patient) were obtained for histological examination and quantitative lung cultures. The presence of both histological pneumonia and positive lung cultures was used as a reference test. RESULTS: The presence of infiltrates on the chest radiograph and two of three clinical criteria (leucocytosis, purulent secretions, fever) had a sensitivity of 69% and a specificity of 75%; the corresponding numbers for the clinical pulmonary infection score (CPIS) were 77% and 42%. Non-invasive as well as invasive sampling techniques had comparable values. The combination of all techniques achieved a sensitivity of 85% and a specificity of 50%, and these values remained virtually unchanged despite the presence of previous treatment with antibiotics. When microbiological results were added to clinical criteria, adequate diagnoses originating from microbiological results which might have corrected false positive and false negative clinical judgements (n = 5) were countered by a similar proportion of inadequate diagnoses (n = 6). CONCLUSIONS: Clinical criteria had reasonable diagnostic values. CPIS was not superior to conventional clinical criteria. Non-invasive and invasive sampling techniques had diagnostic values comparable to clinical criteria. An algorithm guiding antibiotic treatment exclusively by microbiological results does not increase the overall diagnostic accuracy and carries the risk of undertreatment.     

CT引导下穿刺活检在孤立性肺结节的诊断价值

目的探讨CT引导下肺穿刺活检在诊断孤立性肺结节中的价值。材料和方法对56例孤立性肺结节CT引导下进行穿刺活检,观察CT平扫上结节的形态学特点,对穿刺活检术的诊断正确率与病灶的大小、位置、进针深度进行Logistic回归分析,并分析并发症情况。结果56例孤立性肺结节中,41例为恶性,7例为良性,8例活检未获明确诊断。恶性结节较良性结节多见,CT恶性结节表现有空泡征、分叶征、短细毛刺、嵴突征、血管集束征及胸膜凹陷征。CT引导下肺穿刺活检诊断孤立性肺结节的正确率为86%,气胸的发生率为3.6%。Logistic回归发现,病灶的大小是影响穿刺活检正确率的主要因素(Wald=2.903,P=0.038,OR=0.935)。结论CT引导下肺穿刺活检病灶诊断孤立性肺结节临床价值大,准确率较高,而病灶的大小影响穿刺活检的正确率。     

SWE与实时组织弹性成像技术在甲状腺结节良恶性鉴别诊断中的价值分析

目的探究采用剪切波弹性成像(SWE)与实时组织弹性成像技术(RTE)对鉴别诊断甲状腺结节良恶性的价值。方法选择2015年10月至2016年10月收治的行甲状腺手术60例患者进行回顾性分析,共68个甲状腺结节。均在术前同时行SWE检查和RTE检查,并且所有患者均接受手术病理证实。结果 SWE检查甲状腺恶性结节的杨氏模值显著高于良性结节,差异有统计学意义(P0.05)。SWE与RTE两种诊断技术的灵敏度、特异度、阳性预测值及阴性预测值之间的差异无统计学意义(P0.05)。RTE诊断直径≤1 cm甲状腺结节良恶性的灵敏度显著高于SWE,差异有统计学意义(P0.05)。SWE技术诊断直径≥3 cm甲状腺结节良恶性的灵敏度、阳性预测值及阴性预测值均高于RTE,差异有统计学意义(P0.05)。结论 SWE与RTE鉴别诊断甲状腺结节良恶性均具有较高诊断价值,SWE对于大结节良恶性鉴别诊断具有更高价值,而直径≤1 cm的甲状腺结节宜采用RTE技术进行诊断。     

Role of preoperative ultrasonography in the management of thyroid nodules

Ultrasonography is the evidence-based diagnostic method for thyroid nodules. The account has to specify the technical used, and has to exactly describe the echogenicity of the thyroid, the feature of the nodules (number, size, echostructure, echogenicity, edges), and the presence or absence of lymph nodes. The malignancy criteria of thyroid nodules are: (1) hypoechoic solid nodule, (2) presence of internal microcalicifications, (3) ill-defined-irregular edges or absence or breaking of the peripheral halo. The nodes' criteria of malignancy are: (1) diameter of 1 cm or more, (2) clear hypoechoic pattern or non-homogeneous pattern, with alternating hypoechoic and hyperechoic areas, (3) cystic appearance (4) presence of internal calcifications (5) rounded shape with increased anteroposterior diameter, (6) long/short diameter ratio higher than 0.7, (7) absence of hilum. When these criteria are present, a histological diagnosis has to be performed. They could change the operative procedure in the patients.     

无症状健康体检者胸部低剂量CT在早期肺癌筛查中的实用价值

目的评估无症状健康体检者胸部低剂量螺旋CT(LDCT)在早期肺癌筛查中的实用价值。 方法选择2016年1月—2017年12月在内蒙古自治区呼和浩特市第一医院进行无症状健康体检者3 730例,均经LDCT和X线胸片检查,对比分析诊断的准确性,评价LDCT在早期肺癌筛查中的实用价值。 结果所有受检者顺利完成LDCT扫描和X线胸片筛查,检查图像达到临床诊断标准。3 730例受检者中LDCT检查阳性病变者1 112例,其中肺癌2.96%,肺结核8.63%,结节38.31%,支气管扩张3.59%,肺气肿15.82%,肺大疱10.70%,炎症4.13%,其他15.82%。其中426例肺结节中,炎性结节38.26%,实性结节41.31%,磨玻璃样结节19.95%。3 730例受检者中X线胸片检查阳性病变者812例,包括肺癌2.95%,肺结核11.20%,结节27.22%,支气管扩张3.94%,肺气肿20.32%,肺大疱11.94%,炎症4.80%,其他良性陈旧性疾病17.61%。LDCT检查阳性组和X线胸片检查阳性组患者的肺癌、肺部结节、其他疾病的阳性结果例数、检出率及检出准确率比较,差异均有统计学意义(P<0.05)。 结论在年龄≥40岁人群的大规模体检中,LDCT对早期肺癌的筛查具有良好的诊断价值。     

Diagnostic imaging techniques in thyroid cancer

With the refinement of fine-needle aspiration, the specific applications of thyroid imaging techniques need to be reevaluated for efficiency and cost containment. No thyroid imaging test should be routinely obtained. Radionuclide scanning is most beneficial in evaluating the functional status of thyroid nodules when fine-needle aspiration is inadequate, the findings are benign, or when there is no discrete nodule that is palpated in an enlarged gland. When fine-needle aspiration is unavailable or unreliable, radionuclide scanning becomes a first-line diagnostic tool. Ultrasonography should be used primarily for identifying a solid component of a cystic nodule, determining the size of nodules on thyroxine suppression that are not easily palpable, or for performing guided fine-needle aspiration. Computerized tomography and magnetic resonance imaging both have a definite role in the evaluation of thyroid tumors. Magnetic resonance imaging is superior to computerized tomography for the evaluation of metastatic, retrotracheal, or mediastinal involvement of large thyroid tumors or goiters. Careful selection of the diagnostic techniques will ensure more accurate diagnosis and reduce unnecessary patient costs in the treatment of thyroid cancer.     

Fine-needle aspiration may miss a third of all malignancy in palpable thyroid nodules: a comprehensive literature review

BACKGROUND: Fine-needle aspiration (FNA) is currently the primary diagnostic procedure in diagnosing thyroid malignancy and guides surgeons on patient selection for thyroidectomy for thyroid nodules. Diagnostic sensitivity is reported to be approximately 80%; however, patients with negative FNA results do not necessarily undergo surgery and are often not considered in statistical analysis. This may lead to bias in previous reported sensitivity of FNA. The aim of this study was to assess the diagnostic performance attributes of FNA based on a comprehensive review and summary of previous literature. METHODS: A comprehensive review of published literature from 1966 to 2005 was performed, using structured selection and appraisal methods to include all studies that have assessed the sensitivity of FNA for detecting thyroid malignancy in palpable thyroid nodules. A statistical modeling study was designed to estimate the possible true sensitivity and specificity of FNA. RESULTS: Twelve studies fulfilled inclusion criteria and were included in the review. Only 1 study had greater than 25% of patients with negative FNA results who proceeded to thyroidectomy. Statistical modeling indicated that the sensitivity of FNA is highly dependent on the risk of malignancy in the patients with negative FNA results who did not undergo thyroidectomy; in the "same risk" scenario, where the risk of malignancy in the whole group with negative FNA result was assumed to be the same as that in patients with negative FNA results who underwent surgical biopsy; sensitivity could be as low as 66% (confidence interval [CI]: 65-68%). CONCLUSION: Based on existing reports, the true diagnostic attributes of FNA for thyroid malignancy in palpable nodules are uncertain and FNA could miss up to a third of all thyroid malignancy. Further research is required to investigate the incidence of malignancy in FNA negative cases and to determine the additive effect of clinical judgment.     

The potential impact of needle biopsy on surgery for thyroid nodules

Current techniques with fine and cutting needle biopsies permit greatly improved selection of patients with thyroid nodules for operation. A diagnosis of definite or probable carcinoma was confirmed in 95% of 76 patients, and the addition of the category of indeterminate cellular nodule resulted in an overall frequency of carcinoma in 86%. Therefore, the frequency of operations for benign thyroid nodules was dramatically decreased. Critical for the use of needle biopsy of the thyroid is experience in obtaining an adequate and representative sample of the nodule, as well as in cytologic and histologic interpretation of the tissue. Results of needle biopsy of thyroid nodules should be correlated with clinical findings even though the latter criteria provide a much less accurate index of the need of operation. The frequency of carcinoma in patients selected for operation can be increased from the 15% to 30% experienced in the past to a level of approximately 85% by needle biopsy. Thyroid nodules that are recognized as cellular by needle biopsy, but in which carcinoma cannot be ruled out should be treated surgically. Improved selectivity for operation for thyroid nodules has not yet significantly reduced the total number of patients undergoing operation in our practice. Some thyroid nodules that would have been treated nonoperatively in the past are now recognized as needing surgery. Operative eradication of nodules that have been considered clinically benign and managed as such in the past, but which are now recognized as being actual or possible carcinoma by needle biopsy conceivably will reduce the frequency of anaplastic or invasive carcinoma in the future. Falsenegative results have been recognized in 1% or less of patients. A preoperative diagnosis of thyroid carcinoma by needle biopsy permits an immediate, definitive surgical procedure, and changes the operative approach for such patients. Needle biopsy of thyroid nodules can reduce procrastination in making a decision for a surgical or medical approach to the management of thyroid nodules.     

Significance of non-calcified pulmonary nodules in patients with extrapulmonary cancers

BACKGROUND: This study sought to determine the rate and patterns of malignancy in patients with extrapulmonary cancers and non-calcified pulmonary nodules, and to develop a statistical model to guide clinicians regarding choice of patients for diagnostic biopsy. METHOD: The medical records of 151 patients evaluated at the Memorial Sloan-Kettering Cancer Center between January 1999 and December 2001 for non-calcified pulmonary nodules were reviewed. Nodules were considered malignant based on the results of a diagnostic biopsy, and were considered benign if their appearance remained stable 2 years after the initial study, if they resolved, or if a biopsy showed a non-malignant condition. RESULTS: Sixty four of 151 patients (42%) were diagnosed with malignant nodules; 32 had newly diagnosed lung cancers, 28 had metastatic spread of their primary cancers, and four had lesions that were either new cancers or of undetermined aetiology. On univariate analysis the likelihood of malignancy increased with nodule size, tobacco exposure, and the finding of a solitary nodule. On multivariable analysis only nodule size and tobacco exposure were predictive of malignancy. The model had good predictive accuracy (area under the curve 0.751) but had insufficient discrimination for use as a clinical tool to determine which patients should undergo diagnostic biopsy. CONCLUSION: Nearly half the non-calcified pulmonary nodules identified in this series were malignant. Lung cancer was more common than metastatic disease. These findings support the need for close interval follow up and a low threshold for diagnostic biopsy in patients with extrapulmonary cancers and non-calcified pulmonary nodules. In smokers, such lesions should raise concern for lung cancer.     

The reliability of computer tomography for the diagnosis and differential diagnosis of meningiomas,gliomas, and brain metastases

Summary The CT characteristics were studied in a series of 90 tumours, and the diagnostic criteria were determined for meningiomas glioblastomas, other gliomas and metastases. These criteria were then employed in another group of 46 tumours in which the histological diagnosis was not known at the time of examination. The over-all diagnostic accuracy was 85%, and it was largely the same for the various sub-groups.Careful combination of the CT characteristics, perfect techniques, and increased experience may further improve the diagnostic accuracy.     

甲状腺影像报告与数据系统、声触诊组织量化技术及超声造影鉴别诊断甲状腺结节良恶性

目的探讨甲状腺影像报告与数据系统(TI-RADS)分类、声触诊组织量化(VTQ)技术及CEUS对甲状腺结节良恶性的鉴别诊断价值。方法对66例患者69个结节均于术前进行TI-RADS分类、CEUS,观察并分析其CEUS表现。采用VTQ测定结节剪切波速度(SWV),绘制ROC曲线获得SWV的曲线下面积及最佳临界值。计算3种方法单独及两两联合的敏感度、特异度、阳性预测值、阴性预测值及准确率。结果 69个甲状腺结节中,良性37个,恶性32个。3种方法单独诊断时,VTQ诊断甲状腺恶性结节的敏感度最高[87.50%(28/32)],CEUS特异度最高[91.89%(34/37)],两两联合应用时,VTQ和CEUS联合诊断甲状腺恶性结节的敏感度最高[93.75(30/32)]。SWV以2.55 m/s为最佳临界值,ROC曲线下面积为0.808(P0.01)。结论 3种方法均对诊断甲状腺结节良恶性有一定价值,VTQ联合CEUS的敏感度最高,是鉴别甲状腺结节良恶性的可靠检查手段。