Transcranial ultrasound analysis of cerebral blood flow during induced hypertension in acute ischemic stroke - a case series

Background

Current recommendations of stroke treatment favour a moderately elevated blood pressure in the acute phase, based on the concept of an improved cerebral perfusion. Here, cerebral blood flow was assessed in a case series of patients with acute hemodynamic stroke by means of transcranial colour-coded sonography (TCCS) to study the effects of pharmacologically induced hypertension.

Findings

We investigated six patients with acute hemodynamic stroke and blood pressure-dependent clinical fluctuation of neurological symptoms. TCCS was performed during the initiation phase of catecholamine-induced controlled hypertension. A blood pressure-dependent increase of flow velocity in the ipsilesional middle and the posterior cerebral artery was found in all patients (mean increase 0.80% and 0.65% per mmHg, respectively).

Conclusions

Catecholamine-induced hypertension in severe hemodynamic stroke leads to an ultrasound-detectable rise of cerebral blood flow. This finding gives ‘proof-of-principle’ evidence, supporting active blood pressure management in this selected group of stroke patients. Outcome-related questions of target blood pressure, treatment duration or applicability to other forms of stroke, however, remain to be studied. In this, transcranial ultrasound may be a valuable tool for patient selection and subsequent bedside monitoring.     

Current practice of lung ultrasonography (LUS) in the diagnosis of pneumothorax: a survey of physician sonographers in Germany

Background

The purpose of this study was to survey the current practice of the use of lung ultrasonography (LUS) in the diagnosis of pneumothorax.

Methods

Physician sonographers, accredited for diagnostic ultrasonography in surgery, anaesthesia and medicine were studied. Questions addressed the frequency of exposure to patients with suspected pneumothorax, frequency of LUS use, preferences regarding technical aspects of LUS examination, assessment of diagnostic accuracy of LUS and involvement in teaching.

Results

Of the respondents, 55.1% used LUS ‘always’ or ‘frequently’ for suspected pneumothorax. Also, 35.5% of physicians rated LUS as ‘always reliable’ in ruling out pneumothorax, and 21.3% of respondents rated LUS as ‘always reliable’ in ruling in pneumothorax. The mode of performing LUS for pneumothorax was highly variable.Statistically significant differences were found regarding the likelihood of LUS usage, the combined use of M-Mode and B-mode scanning and the confidence to exclude pneumothorax based on LUS findings for physicians with frequent exposure to pneumothorax cases.

Conclusions

Physicians'' use of LUS in the diagnosis of pneumothorax is modest. Confidence in diagnostic accuracy is not comprehensive. Further research is required to establish the most efficient way of performing LUS in this scenario to achieve the highest possible diagnostic accuracy and reliable documentation of examination results.     

Radiation Safety Issues in Y-90 Microsphere Selective Hepatic Radioembolization Therapy: Possible Radiation Exposure from the Patients

Purpose

The purpose of this study was to estimate the possible external radiation dose to other individuals from patients treated with Y-90 resin microspheres for unresectable hepatocellular carcinoma.

Methods

We designed the study prospectively to estimate the possible radiation dose to other individuals from patients who had been treated with Y-90 microspheres for unresectable hepatocellular carcinoma. We estimated the total effective dose equivalent (TEDE) using two methods: ‘theoretical’ TEDEs according to the administered activity and ‘measured’ TEDE based on the ‘measured’ ambient radiation exposure rate. We compared the results from each method to determine when we can release patients from confinement at the earliest time complying with the patient release criteria.

Results

A total of 20 administrations of Y-90 resin microspheres were done in 18 patients. The average administered activity was 1.2 ± 0.77 (0.28–2.97) GBq. The ‘theoretical’ TEDEs were in the range of 0.8–10 μSv. The ‘measured’ TEDEs were in the range of 2.31–185 μSv. The measured TEDEs tend to be higher than the theoretical TEDEs. The values of theoretical and measured TEDE were both far less than 1 mSv, the upper limit at which the licensee can release a patient without any written documents.

Conclusion

The effective dose equivalent caused by the Y-90 microsphere administered patient is very low. It is safe in terms of radiation safety to the other individuals when Y-90 microsphere radioembolization therapy is done with dose less than 3 GBq. Because the measured TEDE tends to be higher than the theoretical TEDE, it is recommended to use ‘measured’ TEDE for determining patient release.     

Lung ultrasound imaging in avian influenza A (H7N9) respiratory failure

Background

Lung ultrasound has been shown to identify in real-time, various pathologies of the lung such as pneumonia, viral pneumonia, and acute respiratory distress syndrome (ARDS). Lung ultrasound maybe a first-line alternative to chest X-ray and CT scan in critically ill patients with respiratory failure. We describe the use of lung ultrasound imaging and findings in two cases of severe respiratory failure from avian influenza A (H7N9) infection.

Methods

Serial lung ultrasound images and video from two cases of H7N9 respiratory failure requiring mechanical ventilation and extracorporeal membrane oxygenation in a tertiary care intensive care unit were analyzed for characteristic lung ultrasound findings described previously for respiratory failure and infection. These findings were followed serially, correlated with clinical course and chest X-ray.

Results

In both patients, characteristic lung ultrasound findings have been observed as previously described in viral pulmonary infections: subpleural consolidations associated or not with local pleural effusion. In addition, numerous, confluent, or coalescing B-lines leading to ‘white lung’ with corresponding pleural line thickening are associated with ARDS. Extension or reduction of lesions observed with ultrasound was also correlated respectively with clinical worsening or improvement. Coexisting consolidated pneumonia with sonographic air bronchograms was noted in one patient who did not survive.

Conclusions

Clinicians with access to point-of-care ultrasonography may use these findings as an alternative to chest X-ray or CT scan. Lung ultrasound imaging may assist in the efficient allocation of intensive care for patients with respiratory failure from viral pulmonary infections, especially in resource scarce settings or situations such as future respiratory virus outbreaks or pandemics.     

The feasibility of nurse practitioner-performed,telementored lung telesonography with remote physician guidance - ‘a remote virtual mentor’

Background

Point-of-care ultrasound (POC-US) use is increasingly common as equipment costs decrease and availability increases. Despite the utility of POC-US in trained hands, there are many situations wherein patients could benefit from the added safety of POC-US guidance, yet trained users are unavailable. We therefore hypothesized that currently available and economic ‘off-the-shelf’ technologies could facilitate remote mentoring of a nurse practitioner (NP) to assess for recurrent pneumothoraces (PTXs) after chest tube removal.

Methods

The simple remote telementored ultrasound system consisted of a handheld ultrasound machine, head-mounted video camera, microphone, and software on a laptop computer. The video output of the handheld ultrasound machine and a macroscopic view of the NP''s hands were displayed to a remote trauma surgeon mentor. The mentor instructed the NP on probe position and US machine settings and provided real-time guidance and image interpretation via encrypted video conferencing software using an Internet service provider. Thirteen pleural exams after chest tube removal were conducted.

Results

Thirteen patients (26 lung fields) were examined. The remote exam was possible in all cases with good connectivity including one trans-Atlantic interpretation. Compared to the subsequent upright chest radiograph, there were 4 true-positive remotely diagnosed PTXs, 2 false-negative diagnoses, and 20 true-negative diagnoses for 66% sensitivity, 100% specificity, and 92% accuracy for remotely guided chest examination.

Conclusions

Remotely guiding a NP to perform thoracic ultrasound examinations after tube thoracostomy removal can be simply and effectively performed over encrypted commercial software using low-cost hardware. As informatics constantly improves, mentored remote examinations may further empower clinical care providers in austere settings.     

Is B-mode ultrasound alone a sufficient screening tool for carotid stenosis? A pilot study

Background

Carotid ultrasound is performed solely in hospital ultrasound departments or outpatient labs, using both B- and Doppler modes. We hypothesize that B-mode without Doppler can be used to classify patients as having carotid stenosis (CS) above or below 50%. Our objective is to determine the frequency with which a CS >50% is found using Doppler when no such stenosis was visible using B-mode.

Methods

This was a retrospective study of 100 patients referred to the stroke clinic and 100 patients referred for carotid endarterectomy (CEA). All patients had an elective carotid ultrasound done at Health Sciences North. The ultrasound reports were mixed together and blinded. Investigators determined if there was a CS of greater or less than 50% based on the carotid diagram. These results were compared to the degree of CS found on Doppler.

Results

In the CEA group, there were 198 ultrasounds, with 153 showing a CS of >50%. Only one case of CS >50% was missed by B-mode. In the clinic group, 32 of 192 ultrasounds showed a CS of >50%. None were missed by B-mode. B-mode had a sensitivity and negative predictive value of 100% and a specificity of 65%.

Conclusion

This study supports the theory that it may be possible to use B-mode ultrasound without Doppler to reliably determine if there is CS above or below 50%. Further research is required before carotid ultrasound using B-mode alone can be recommended.     

Endovascular Treatment of Traumatic Pseudoaneurysm Presenting as Intractable Epistaxis

Objective

To investigate the clinical efficacy of individual endovascular management for the treatment of different traumatic pseudoaneurysms presenting as intractable epistaxis.

Materials and Methods

For 14 consecutive patients with traumatic pseudoaneurysm presenting as refractory epistaxes, 15 endovascular procedures were performed. Digital subtraction angiography revealed that the pseudoaneurysms originated from the internal maxillary artery in eight patients; and all were treated with occlusion of the feeding artery. In six cases, they originated from the internal carotid artery (ICA); out of which, two were managed with detachable balloons, two with covered stents, one by means of cavity embolization, and the remaining one with parent artery occlusion. All of these cases were followed up clinically from six to 18 months, with a mean follow up time of ten months; moreover, three cases were also followed with angiography.

Results

Complete cessation of bleeding was achieved in all the 15 instances (100%) immediately after the endovascular therapies. Of the six patients who suffered from ICA pseudoaneurysms, one presented with a permanent stroke and one had an episode of rebleeding requiring intervention.

Conclusion

In patients presenting with a history of craniocerebral trauma, traumatic pseudoaneurysm must be considered as a differential diagnosis. Individual endovascular treatment is a relatively safe, plausible, and reliable means of managing traumatic pseudoaneurysms.     

Usefulness of 18F-FDG PET/CT for the Evaluation of Bone Marrow Involvement in Patients with High-Grade Non-Hodgkin’s Lymphoma

Purpose

To assess the usefulness of ¹⁸F-fluorodeoxyglucose PET/CT in the detection of bone marrow (BM) involvement of high-grade non-Hodgkin’s lymphoma (NHL).

Methods

One hundred twenty patients with newly diagnosed diffuse large B-cell lymphoma or peripheral T-cell lymphoma between January 2007 and June 2011, who received BM trephine biopsy and ¹⁸F-FDG PET/CT before chemotherapy, were included in this retrospective study. We reviewed their ¹⁸F-FDG PET/CT images and bone marrow biopsy (BMB) results. After reviewing the images, we reviewed the medical records and radiological findings of interesting patients.

Results

There were 23 ¹⁸F-FDG PET/CT scans in which the marrow was considered to be abnormal (either positive or equivocal), and 97 ¹⁸F-FDG PET/CT scans were regarded as having negative FDG uptake. Of 120 patients, 100 (83.3 %) had a concordant result of BM interpretation between ¹⁸F-FDG PET/CT and BMB, and the remaining 20 patients had discordant results. Among 23 patients with either positive or equivocal ¹⁸F-FDG PET/CT scans, 1 of 12 patients with ‘positive’ ¹⁸F-FDG PET/CT had a lymphomatous involvement on BMB. In contrast, 10 of 11 patients with ‘equivocal’ BM hypermetabolism were reported as having positive involvement by BMB. Patients with abnormal ¹⁸F-FDG PET/CT had significantly higher mSUV_highest than those with normal FDG-PET/CT.

Conclusions

¹⁸F-FDG PET/CT and BMB are complementary techniques in assessing the presence of BM involvement in patients with high-grade NHL. The increasing availability of ¹⁸F-FDG PET/CT will raise the need for additional biopsy for FDG-avid lesions, especially in patients with negative standard BMBs. ¹⁸F-FDG PET/CT can be useful as a decision-making tool for determining whether to perform a standard BMB or targeted biopsy to the FDG-avid lesion as an initial staging procedure. A direct bone biopsy for FDGpositive bone lesions should be included in staging guidelines in future. In ¹⁸F-FDG PET/CT-negative cases, BMB is still a powerful procedure, but BMB alone is insufficient for full evaluation of BM.     

Immediate versus delayed integrated point-of-care-ultrasonography to manage acute dyspnea in the emergency department

Background

Dyspnea is one of the most frequent complaints in the Emergency Department. Thoracic ultrasound should help to differentiate cardiogenic from non-cardiogenic causes of dyspnea. We evaluated whether the diagnostic accuracy can be improved by adding a point-of-care-ultrasonography (POC-US) to routine exams and if an early use of this technique produces any advantage.

Methods

One hundred sixty-eight patients were enrolled and randomized in two groups: Group 1 received an immediate POC-US in addition to routine laboratory and instrumental tests; group 2 received an ultrasound scan within 1 h from the admission to the Emergency Department. The concordance between initial and final diagnosis and the percentage of wrong diagnosis in the two groups were evaluated. Mortality, days of hospitalization in Emergency Medicine department and transfers to other wards were compared. Sensitivity and specificity of the routine protocol and the one including ultrasonography for the diagnosis of the causes of dyspnea were also analyzed.

Results

Eighty-eight patients were randomized in group 1 and 80 in group 2. The concordance rate between initial and final diagnoses was significantly different (0.94 in group 1 vs. 0.22 in group 2, p < 0.005). The percentage of wrong initial diagnosis was 5% in group 1 and 50% in group 2 (p < 0.0001).

Conclusions

Adding POC-US to routine exams improves the diagnostic accuracy of dyspnea and reduces errors in the Emergency Department.     

Quantified ultrasound elastography in the assessment of cutaneous carcinoma

Objective:

To evaluate the feasibility of high-frequency ultrasound and ultrasound elastography (USE) in discriminating benign from malignant skin lesions in a prospective cohort study and to introduce the use of a “strain ratio” for evaluation of skin lesions.

Methods:

A commercial ultrasound system with a 14-MHz transducer was used to visualize skin lesions requiring biopsy on clinical evaluation. Anatomic ultrasound and USE imaging of the skin lesions was performed using 2- to 4-mm gel stand-off pads. A region of interest was manually selected over the area of each lesion with the lowest strain. The concept of a strain ratio of the compressibility of the normal skin at the corresponding layer to that of the least compressible region of a lesion in question was created and applied. This ratio was subsequently correlated with blind histopathological evaluation for malignancy.

Results:

55 patients were included in the study with a total of 67 lesions evaluated. 29 lesions were malignant and 38 benign. All malignant lesions had strain ratios ≥3.9. All benign lesions had strain ratios ≤3.0. A diagnostic value between 3.0 and 3.9 would result in 100% sensitivity and specificity in the characterization of these lesions as malignant.

Conclusion:

This pilot study demonstrated that USE plus strain ratio appears to be a promising modality in providing diagnostic determination between cancerous and benign primary solitary skin lesions prior to biopsy.

Advances in knowledge:

This is the first reported study applying an original mathematical elastographic ratio, or strain ratio, to evaluate primary solitary skin lesions.     

Computed tomographic pulmonary changes in patients with chronic rhinosinusitis

Objective:

To investigate whether patients with a diagnosis of chronic rhinosinusitis (CRS) show characteristic pulmonary changes on chest CT compared with a control group without sinusopathy.

Methods:

This retrospective, observational study included patients with and without a diagnosis of CRS who underwent CT examination of the lungs between 2012 and 2014. Two radiologists, who were blinded for the presence of CRS, reviewed the scans for the presence of any abnormalities consensually. The χ² test was used for correlative analysis, with a significance level of 0.05.

Results:

A total of 123 CT series (51.2% from male patients, mean age 41 ± 16 years) were reviewed, including those from 59 (48%) patients with a diagnosis of CRS. Patients with CRS were more likely than the control group to exhibit atelectasis, bronchiolectasis, centrilobular nodules and ground-glass opacities (all p < 0.05), with a significant predilection for middle lobe and lingular involvement observed (p < 0.001). Other abnormalities, such as bronchial wall thickening and air trapping, did not differ between groups.

Conclusion:

Atelectatic changes, ground-glass opacities, bronchiolectasis and centrilobular nodules are the most frequent abnormalities associated with CRS, with peculiar middle lobe and lingular involvement observed on chest CT examinations.

Advances in knowledge:

CRS is a frequent disorder that displays typical pulmonary changes at CT. The recognition of such findings can prevent patients with this condition from undergoing unnecessary investigations that might be based on the presence of the aforementioned radiological features.     

Does 131I Radioactivity Interfere with Thyroglobulin Measurement in Patients Undergoing Radioactive Iodine Therapy with Recombinant Human TSH?

Objectives

Recombinant human thyroid-stimulating hormone (rhTSH) is widely used in radioactive iodine therapy (RIT) to avoid side effects caused by hypothyroidism during the therapy. Owing to RIT with rhTSH, serum thyroglobulin (Tg) is measured with high ¹³¹I concentrations. It is of concern that the relatively high energy of ¹³¹I could interfere with Tg measurement using the immunoradiometric assay (IRMA). We investigated the effect of ¹³¹I administration on Tg measurement with IRMA after RIT.

Methods

A total of 67 patients with thyroid cancer were analysed retrospectively. All patients had undergone rhTSH stimulation for RIT. The patients’ sera were sampled 2 days after ¹³¹I administration and divided into two portions: for Tg measurements on days 2 and 32 after ¹³¹I administration. The count per minute (CPM) of whole serum (200 μl) was also measured at each time point. Student’s paired t-test and Pearson’s correlation analyses were performed for statistical analysis.

Results

Serum Tg levels were significantly concordant between days 2 and 32, irrespective of the serum CPM. Subgroup analysis was performed by classification based on the ¹³¹I dose. No difference was noted between the results of the two groups.

Conclusions

IRMA using ¹²⁵I did not show interference from ¹³¹I in the serum of patients stimulated by rhTSH.     

Ultrasound analysis of mental artery flow in elderly patients: a case–control study

Objectives:

Mental artery flow decreases with age and may have an aetiological role in alveolar ridge atrophy. The aim of this study was to identify factors associated with alterations of mental artery flow, assessed by ultrasonography.

Methods:

This case–control study was conducted on elderly patients (aged above 60 years) at the beginning of dental treatment. Intraoral B-mode Doppler ultrasonography was used to assess mental artery flow. The cases were defined as patients with a weak/absent ultrasound signal, whereas the controls presented a strong ultrasound signal. Demographics and radiographic findings (low bone mineral density on dual-energy X-ray absorptiometry and mandibular cortical index on panoramic radiographs) were analysed as risk factors for weak/absent ultrasound signal and were calculated as adjusted odds ratios (AORs) with 95% confidence intervals (CIs) using conditional logistic regression. In addition, the Student''s t-test was used to compare the mean alveolar bone height of the analysed groups. A p-value <0.05 was considered statistically significant.

Results:

A total of 30 ultrasound examinations (12 cases and 18 controls) were analysed. A weak/absent mental artery pulse strength was significantly associated with edentulism (AOR = 3.67; 95% CI = 0.86–15.63; p = 0.046). In addition, there was a significant difference in alveolar bone height between edentulous cases and controls (p = 0.036).

Conclusions:

Within the limitations of this study, the present results indicate that edentulism is associated with diminished mental artery flow, which, in turn, affects alveolar bone height.     

Radiography,Bone Scan,and F-18 FDG PET/CT Imaging Findings in a Patient with Paget’s Disease

Background

A 52-year-old female patient sought evaluation at our hospital for an incidental abnormal finding on an abdominal radiograph.

Methods

The initial radiograph showed irregular sclerotic changes involving the right pelvic bone. At the same time, bone scintigraphy showed intense hot uptake in the right iliac and pubic bones. CT images showed characteristic thickening of the pelvic brim, suggesting the mixed phase of Paget’s disease.

Results

The level of alkaline phosphatase (ALP) was 266 IU/l. ¹⁸F-FDG PET/CT images also showed diffusely increased ¹⁸F-FDG uptake in the right pelvic bone. However, the findings of ¹⁸F-FDG PET/CT were less notable than those of bone scintigraphy.

Conclusion

We report the imaging findings of a patient with Paget’s disease evaluated by radiography, bone scintigraphy, and ¹⁸F-FDG PET/CT.     

Radiofrequency Ablation to Treat Loco-Regional Recurrence of Well-Differentiated Thyroid Carcinoma

Objective

To evaluate the efficacy of radiofrequency ablation (RFA) in the treatment of loco-regional, recurrent, and well-differentiated thyroid carcinoma.

Materials and Methods

Thirty-five recurrent well-differentiated thyroid carcinomas (RTC) in 32 patients were treated with RFA, between March 2008 and October 2011. RTCs were detected by regular follow-up ultrasound and confirmed by biopsy. All patients had fewer than 3 RTCs in the neck and were at high surgical risk or refused to undergo repeated surgery. Average number of RFA sessions were 1.3 (range 1-3). Post-RFA biopsy and ultrasound were performed. The mean follow-up period was 30 months. Pre- and post-RFA serum thyroglobulin values were evaluated.

Results

Thirty-one patients with 33 RTCs were treated with RFA only, whereas 1 patient with 2 RTCs was treated with RFA followed by surgery. At the last follow-up ultrasound, 31 (94%) of the 33 RTCs treated with RFA alone completely disappeared and the remaining 2 (6%) RTCs showed decreased volume. The largest diameter and volume of the 33 RTCs were markedly decreased by 93.2% (from 8.1 ± 3.4 mm to 0.6 ± 1.8 mm, p < 0.001) and 96.4% (from 173.9 ± 198.7 mm³ to 6.2 ± 27.9 mm³, p < 0.001), respectively. Twenty of the 21 RTCs evaluated with post-RFA biopsies (95%) were negative for malignancy. One (5%) showed remaining tumor that was removed surgically. The serum thyroglobulin was decreased in 19 of 26 patients (73%). Voice change developed immediately after RFA in 6 patients (19%) and was spontaneously recovered in 5 patients (83%).

Conclusion

Radiofrequency ablation can be effective in treating loco-regional, recurrent, and well-differentiated thyroid carcinoma in patients at high surgical risk.     

Precision imaging—its impact on image quality and diagnostic confidence in breast ultrasound examinations

Objective:

To determine the effect of noise-reducing innovation—precision imaging (PI)—on image quality and diagnostic efficacy in breast ultrasound.

Methods:

The study, which assessed four levels of PI from zero to three, consisted of two parts: image quality assessment and diagnostic efficacy evaluation. For the first part, 247 sets of ultrasound images displayed at each PI level were evaluated by 6 experienced breast imaging observers, by rating image quality using visual grading analysis on a 1–4 scale. For the diagnostic efficacy part 51 breast lesions were displayed at each PI level and scored 1–6 to generate a receiver operating characteristic (ROC) curve. These images were evaluated by radiologists and sonographers. Analyses were performed using non-parametric Friedman and Wilcoxon signed rank tests and a multireader multicase methodology.

Results:

Statistically, higher scores of image quality were observed with increased levels of PI than with the zero setting (p < 0.001). The ROC analysis did not demonstrate any significant change in diagnostic efficacy, with mean scores for all observers being 0.79, 0.80, 0.81 and 0.81 for settings zero, one, two and three, respectively.

Conclusion:

This study suggested a perceived improvement in image quality with increasing levels of PI; however, no changes in diagnostic efficacy were noted. The importance of looking at the impact of new imaging technologies in a multifaceted way is emphasized.

Advances in knowledge:

To our knowledge, this is the first article investigating the impact of the PI algorithm on ultrasound image quality and breast lesion characterization.     

Comparative study of CT appearances in mucinous tubular and spindle cell carcinoma and collecting duct carcinoma of the kidney

Objective:

To characterize the multidetector CT (MDCT) imaging characteristics of mucinous tubular and spindle cell carcinoma (MTSCC) and collecting duct carcinoma (CDC) of the kidney.

Methods:

21 patients with MTSCC and 18 patients with CDC were studied retrospectively. MDCT was undertaken to investigate differences in tumour characteristics.

Results:

Five patients with MTSCC had calcifications as did nine patients with CDC (p = 0.108). In three patients with MTSCC and four patients with CDC, the tumours had a clear boundary (p = 0.682). No patient with MTSCC had retroperitoneal lymph node metastasis as did five patients with CDC (p = 0.015). 16 patients with MTSCC showed homogeneous enhancement, whereas 11 patients with CDC showed heterogeneous enhancement (p = 0.025). The attenuation value of CDC tumours was greater than that of MTSCC and normal renal parenchyma on an unenhanced CT (p = 0.027). MTSCC and CDC tumour enhancement was less than the normal renal cortex and medulla in all phases (p < 0.001). Tumour enhancement was greater for CDC than that for MTSCC in all phases (p = 0.011, p = 0.006 and p = 0.052).

Conclusion:

Unenhanced and dynamic MDCT may aid in diagnosis and differentiation of MTSCC and CDC of the kidney.

Advances in knowledge:

This is the first series evaluating the imaging findings of MTSCC and CDC of which we are aware, and identification of such findings may improve diagnosis of these two rare tumours.     

Detection of the genial spinal canal in atrophic mandibles with a CBCT: a cadaver study

Objectives:

The use of a single midline implant to retain a complete mandibular denture when more implants cannot be used is an incipient treatment modality. However, in the mandibular symphysis, the genial spinal canal (GSC) is an anatomical structure with neurovascular content that can be harmed during dental implant surgery. The purpose of the present study was to use CBCT of edentulous atrophic cadaver mandibles and evaluate how often the simulated placement of a single midline implant would contact the GSC if present.

Methods:

CBCT scans of 47 edentulous cadaver mandibles were performed. A digital simulation of the placement of a single midline implant (3.8 × 11.0 mm) was performed, and the implant–GSC contact was evaluated.

Results:

A GSC was detected in the CBCT scan of all atrophic mandibles. In 42 cases (89.4%), the single midline implant contacted the GSC. On average, the five cases without GSC contact had a higher alveolar ridge (4.1 mm) and a lower GSC (0.79 mm) than did the cases with GSC contact.

Conclusions:

CBCT scans can adequately detect the GSC during pre-surgical diagnostics. There is a high risk of implant–GSC contact during surgery of the anterior mandible. However, the clinical relevance of such a contact is not known yet, because none of the clinical studies evaluating a single midline implant has reported any implant–GSC contact-related complications.     

Evaluation of lymph node status after neoadjuvant chemotherapy in breast cancer patients: comparison of diagnostic performance of ultrasound,MRI and 18F-FDG PET/CT

Objective:

To evaluate the diagnostic performance of ultrasound, MRI and fluorine-18 fludeoxyglucose positron emission tomography (¹⁸F-FDG PET)/CT for the diagnosis of metastatic axillary lymph node (ALN) after neoadjuvant chemotherapy (NAC) and to find out histopathological factors affecting the diagnostic performance of these imaging modalities.

Methods:

From January 2012 to November 2014, 191 consecutive patients with breast cancer who underwent NAC before surgery were retrospectively reviewed. We included 139 patients with ALN metastasis that was confirmed on fine needle aspiration or core needle biopsy at initial diagnosis.

Results:

After NAC, 39 (28%) patients showed negative conversion of ALN on surgical specimens of sentinel lymph node (LN) or ALN. The sensitivity of ultrasound, MRI and PET/CT was 50% (48/96), 72% (70/97) and 22% (16/73), respectively. The specificity of ultrasound, MRI and PET/CT was 77% (30/39), 54% (21/39) and 85% (22/26), respectively. The Az value of combination of ultrasound and PET/CT was the highest (0.634) followed by ultrasound (0.626) and combination of ultrasound, MRI and PET/CT (0.617). The size of tumour deposit in LN and oestrogen receptor was significantly associated with the diagnostic performance of ultrasound (p < 0.001 and p = 0.009, respectively) and MRI (p = 0.045 and p = 0.036, respectively). The percentage diameter decrease, size of tumour deposit in LN, progesterone receptor, HER2 and histological grade were significantly associated with the diagnostic performance of PET/CT (p = 0.023, p = 0.002, p = 0.036, p = 0.044 and p = 0.008, respectively). On multivariate logistic regression analysis, size of tumour deposit within LN was identified as being independently associated with diagnostic performance of ultrasound [odds ratio, 13.07; 95% confidence interval (CI), 2.95–57.96] and PET/CT (odds ratio, 6.47; 95% CI, 1.407–29.737).

Conclusion:

Combination of three imaging modalities showed the highest sensitivity, and PET/CT showed the highest specificity for the evaluation of ALN metastasis after NAC. Ultrasound alone or combination of ultrasound and PET/CT showed the highest positive-predictive value. The size of tumour deposit within ALN was significantly associated with diagnostic performance of ultrasound and PET/CT.

Advances in knowledge:

This study is about the diagnostic performance of ultrasound, MRI, PET/CT and combination of each imaging modality for the evaluation of metastatic ALN after NAC. Of many histopathological factors, only the size of tumour deposit within ALN was an independent factor associated with the diagnostic performance of ultrasound and PET/CT.Axillary lymph node (ALN) metastasis is one of the most significant prognostic factors in patients with breast cancer. As the management of axillary lesions has been diverse, the detection of axillary nodal lesion has been more important. The diagnostic accuracy of ultrasound and MRI for the detection of metastatic ALNs has been studied by many researchers. Sensitivity and specificity of ultrasound for the detection of metastatic ALNs have been reported as 41.2–70.8% and 54.5–93.7%.^1–4 Sensitivity and specificity of MRI have been reported as 36–79% and 93–100%, respectively.^4–6Neoadjuvant chemotherapy (NAC) has become the standard treatment not only in patients with locally advanced breast cancer but also in early invasive breast cancer in an attempt to downstage the primary cancer and to reduce micrometastasis. If the ALN metastasis is confirmed on fine needle aspiration biopsy (FNAB) or core needle biopsy (CNB) at initial diagnosis, ALN dissection (ALND) is usually performed, regardless of the responsiveness of ALN. Residual metastatic lesion of ALNs after NAC is an important prognostic factor of disease-free survival.^7,8In ACOSOG Z1071 trial, in patients with breast cancer with clinical N1 stage receiving NAC, if two or more sentinel lymph nodes (SLNs) were removed, the false-negative rate of SLN biopsy (SLNB) was relatively low, 12.6%. Therefore, the role of axillary imaging in NAC setting should be to find out metastatic lymph nodes (LNs) for surgeons to proceed directly to ALND. Another role could be to correctly diagnose negative LN to safely omit SLNB. Despite the importance of restaging of nodal status, there have been few studies about diagnostic accuracy of imaging modalities for detection of metastatic ALNs after NAC.The purpose of our study was to evaluate the diagnostic performance of ultrasound, MRI and fluorine-18 fludeoxyglucose positron emission tomography (¹⁸F-FDG PET)/CT for the diagnosis of metastatic ALNs after NAC and to find out histopathological factors affecting the diagnostic accuracy of these imaging modalities.