Application of contrast-enhanced intraoperative ultrasonography in the decision-making about hepatocellular carcinoma operation

AIM:To evaluate the detection and differentiation ability of contrast-enhanced intraoperative ultrasonography(CE-IOUS) in hepatocellular carcinoma(HCC) operations.METHODS:Clinical data of 50 HCC patients were retrospective analyzed.The sensitivity,specificity,false negative and false positive rates of contrast enhanced magnetic resonance imaging(CE-MRI),IOUS and CEIOUS were calculated and compared.Surgical strategy changes due to CE-IOUS were analyzed.RESULTS:Lesions detected by CE-MRI,IOUS and CEIOUS were 60,97 and 85 respectively.The sensitivity,specificity,false negative rate,false positive rate of CEMRI were 98.2%,98.6%,98.6%,60.0%,respectively;for IOUS were 50.0%,90.9%,1.8%,1.4%,respectively;and for CE-IOUS were 1.4%,40.0%,50.0%,9.1%,respectively.The operation strategy of 9(9/50,18.0%) cases was changed according to the results of CE-IOUS.CONCLUSION:Compared with CE-MRI,CE-IOUS performs better in detection and differentiation of small metastasis and regenerative nodules.It plays an important role in the decision-making of HCC operation.

Contrast-enhanced ultrasonography in the evaluation of incidental focal liver lesions: A cost-effectiveness analysis

AIM To determine whether contrast-enhanced ultrasonography(CEUS) as the first-line method is more costeffective in evaluating incidentally discovered focal liver lesions(FLLs) than is computed tomography(CT) and magnetic resonance imaging(MRI). METHODS Between 2010 and 2015, our prospective study enrolled 459 patients with incidentally found FLLs. The biological nature of FLLs was assessed by CEUS in all patients. CT or MRI examinations were added in unclear cases. The sensitivity and specificity of CEUS were calculated. The total costs of CEUS examinations and of the added examinations performed in inconclusive cases were calculated. Afterwards, the theoretical expenses for evaluating incidentally discovered FLLs using CT or MRI as the first-line method were calculated. The resultswere compared. RESULTS The total cost of the diagnostic process using CEUS for all enrolled patients with FLLs was 75884 USD. When the expenses for additional CT and MRI examinations performed in inconclusive cases were added, the total cost was 90540 US dollar(USD). If all patients had been examined by CT or MR as the first-line method, the costs would have been 78897 USD or 384235 USD, respectively. The difference between the cost of CT and CEUS was 3013 USD(4%) and that between MRI and CEUS was 308352 USD(406.3%). We correctly described 97.06% of benign or malignant lesions, with 96.99% sensitivity and 97.09% specificity. Positive predictive value was 94.16% and negative predictive value was 98.52%. In cases with 4 and more lesions, malignancy is significantly more frequent and inconclusive findings significantly less frequent(P < 0.001).CONCLUSION While the costs of CEUS and CT in evaluating FLLs are comparable, CEUS examination is far more costeffective in comparison to MRI.

Impact of the arterial input function on microvascularization parameter measurements using dynamic contrast-enhanced ultrasonography

AIM: To evaluate the sources of variation influencing the microvascularization parameters measured by dynamic contrast-enhanced ultrasonography (DCE-US). METHODS: Firstly, we evaluated, in vitro , the impact of the manual repositioning of the ultrasound probe and the variations in flow rates. Experiments were conducted using a custom-made phantom setup simulating a tumor and its associated arterial input. Secondly, we evaluated, in vivo , the impact of multiple contrast agent injections and of examination day, as well as the influence of the size of region of interest (ROI) associated with the arterial input function (AIF). Experiments were conducted on xenografted B16F10 female nude mice. For all of the experiments, an ultrasound scanner along with a linear transducer was used to perform pulse inversion imaging based on linear raw data throughout the experiments. Semi-quantitative and quantitative analyses were performed using two signal-processing methods. RESULTS:In vitro , no microvascularization parameters, whether semi-quantitative or quantitative, were significantly correlated (P values from 0.059 to 0.860) with the repositioning of the probe. In addition, all semiquantitative microvascularization parameters were correlated with the flow variation while only one quantitative parameter, the tumor blood flow, exhibited P value lower than 0.05 (P = 0.004). In vivo , multiple contrast agent injections had no significant impact (P values from 0.060 to 0.885) on microvascularization parameters. In addition, it was demonstrated that semi-quantitative microvascularization parameters were correlated with the tumor growth while among the quantitative parameters, only the tissue blood flow exhibited P value lower than 0.05 (P = 0.015). Based on these results, it was demonstrated that the ROI size of the AIF had significant influence on microvascularization parameters: in the context of larger arterial ROI (from 1.17 ± 0.6 mm 3 to 3.65 ± 0.3 mm 3 ), tumor blood flow and tumor blood volume were correlated with the tumor growth, exhibiting P values lower than 0.001. CONCLUSION: AIF selection is an essential aspect of the deconvolution process to validate the quantitative DCE-US method.

Clinical value of contrast-enhanced ultrasound in early diagnosis of small hepatocellular carcinoma (≤ 2 cm)

BACKGROUND Hepatocellular carcinoma(HCC)is the most common type of primary liver malignancy.Contrast-enhanced ultrasound(CEUS)uses contrast microbubbles during ultrasound,allowing the detection and characterization of malignant focal liver lesions with much higher diagnostic accuracy than conventional ultrasound;however,there are few reports focusing on the pattern of enhancement of CEUS for the diagnosis of HCC smaller than 2 cm.AIM To investigate the clinical value of CEUS in the early detection of small HCC with high risk factors.METHODS A total of 395 patients with 632 nodules at high risk of HCC,who underwent regular follow-up at Xuhui Dahua Hospital from January 2007 to December 2021,were retrospectively examined.Conventional ultrasonography combined with CEUS was adopted to analyze the echo,size,location,and enhancement characteristics of benign and malignant nodules,as well as the enhancement methods for HCC with different diameters.RESULTS The follow-up rate and duration were 92.15%(364/395)and 51.28±45.09 mo,respectively.Conventional ultrasonography combined with CEUS revealed 65(11.80%)nodules with a follow-up diagnosis of HCC,19(3.45%)dysplastic nodules,and 467(84.75%)benign cirrhotic hyperplastic nodules.Among 65 cases of confirmed HCC,40(61.54%)were transformed from hypoechoic nodules,9(13.85%)from hyperechoic nodules,and the remaining 16(24.62%)from isoechoic nodules.Significant differences in CEUS characteristics were found among cirrhotic nodules,dysplastic nodules,and HCC nodules at each phase.Significant differences in the enhancement mode were observed between nodules≤1 cm and those 1–2 cm.The smaller the HCC nodule,the later the contrast agent began to flush and the longer the duration of contrast enhancement.CONCLUSION Conventional ultrasonography combined with CEUS could identify small HCC and help monitor patients with an early diagnosis of HCC.Significant differences in the enhancement mode are noted between nodules≤1 cm and those 1–2 cm.

奇异值分解滤波联合Frangi滤波对超微血管成像图像质量的影响

目的 观察奇异值分解(SVD)滤波联合Frangi滤波对超微血管成像(SMI)图像质量的影响。方法 分别对1具仿体及1例疑诊肝血管瘤患者行CEUS,分别以SVD滤波(A组)、Frangi滤波(B组)、Frangi+SVD滤波(C组)及SVD+Frangi滤波(D组)处理图像,之后比较不同图像的质量。结果 4组仿体及人体肝脏SMI对比组织比(CTR)、对比度噪声比(CNR)及信噪比(SNR)均高于原始CEUS图像。相比原始图像,D组图像质量及分辨率提升最为显著,仿体SMI的CTR、CNR及SNR分别提升58.04、3.39及48.04 dB,人体肝脏SMI相应参数则分别提升61.85、16.80及49.67 dB,而分辨率分别为原始CEUS图像的1.42倍及1.98倍。结论 SVD滤波联合Frangi滤波可有效提高SMI图像质量。

Diagnostic sensitivity of imaging modalities for hepatocellular carcinoma smaller than 2 cm

AIM:To compare the imaging results with histology and to evaluate the diagnostic sensitivity of imaging modalities for hepatocellular carcinoma(HCC)smaller than 2 cm.METHODS:Nodules smaller than 2 cm(n=34)revealed by ultrasonography(US)in 29 patients with liver cirrhosis were analyzed.Histological diagnosis of HCC was performed by ultrasonographic guidance:moderately-differentiated HCC(n=24);well-differentiated HCC(n=10).The patterns disclosed by the four imaging modalities defined the conclusive diagnosis of HCC:(1)contrast-enhanced computed tomography(CECT),hypervascularity in the arterial phase and washout in the equilibrium phase;(2)Sonazoid contrast-enhanced US(CEUS),hypervascularity in the early vascular phase and defect in the Kupffer phase;(3)gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid(Gd-EOBDTPA)-enhanced magnetic resonance imaging(MRI),hypervascularity in the arterial phase and/or defect in the hepatobiliary phase;and(4)CT arterioportal angiography:hypervascularity by CT during arteriography and/ or perfusion defect by CT during arterial portography.RESULTS:Overall,the sensitivity of diagnosing HCC smaller than 2 cm was 52.9%(18/34)(95%CI:35.170.2)by CECT;67.6%(23/34)(95%CI:49.5-82.6)by Sonazoid CEUS;76.5%(26/34)(95%CI:58.8-89.3) by Gd-EOB-DTPA MRI;and 88.2%(30/34)(95%CI: 72.5-96.7)by CT arterioportal angiography.The diagnostic sensitivity of detecting moderately-differentiated HCC by CECT,Sonazoid CEUS,Gd-EOB-DTPA MRI and CT arterioportal angiography was 62.5%(15/24)(95%CI: 40.6-81.2),79.2%(19/24)(95%CI:57.8-92.9),75.0% (18/24)(95%CI:53.3-90.2)and 95.8%(23/24)(95% CI:78.9-99.9),respectively.A significant difference(P< 0.05)was observed between CECT and CT arterioportal angiography in all nodules.There was no difference between Sonazoid CEUS,Gd-EOB-DTPA MRI,and CT arterioportal angiography.The combined sensitivity of Sonazoid CEUS and Gd-EOB-DTPA MRI was 94.1%(32/34).CONCLUSION:Changing the main diagnostic modality for HCC smaller than 2 cm from CT arterioportal angiography to Sonazoid CEUS and Gd-EOB-DTPA MRI is recommended.

与 transarterial chemoembolization 对待的 Hepatocellular 癌: 有参量的提高对比的 ultrasonography 的评估

AIM:To evaluate the response of hepatocellular carcinoma(HCC) to transarterial chemoembolization(TACE) using a simplified protocol of parametric contrastenhanced ultrasound(pCEUS).METHODS:Eighteen patients with HCC(18 target tumors,diameter:2.8-12 cm) were evaluated before,and 20 d after TACE.The distribution and morphology of TACE-induced necrosis in these tumors precluded accurate evaluation by visual assessment or by simple measurements.For pCEUS,a 4.8 mL bolus of SonoVue(Bracco,Milan,Italy) was intravenously administered and analysis of tumor perfusion during the initial phase of enhancement(0-30 s post injection) was performed with dedicated software(Qontrast,Bracco,Milan,Italy).Time-intensity curves were plotted and three parameters were calculated:peak intensity(PI,in percentage %),time to peak(TTP in seconds,s) and area under the curve during wash-in(AUC-WI,in arbitrary units,a.u).Magnetic resonance imaging was the standard imaging modality for post-treatment evaluation.Changes in tumor size were recorded and response was assessed according to response evaluation criteria in solid tumors criteria.RESULTS:A statistically significant decrease in PI and AUC-WI was observed in the treated tumors post TACE;PIpre:21.5% ± 8.7%(mean ± SD),PIpost:12.7% ± 6.7%,P 【 0.001,AUC-WI pre:17493 ± 9563 a.u,AUCWI post:9585 ± 5494 a.u,P 【 0.001.A slight increase in TTP was noted post TACE,but this was not statistically significant;TTP pre:13.1 ± 4.3 s,TTP post:13.6 ± 4.2 s,P = 0.058).The changes in the aforementioned parameters were not accompanied by significant tumor shrinkage.CONCLUSION:pCEUS,even when limited to the study of the arterial phase of tumoral enhancement,can detect and quantify early perfusional changes in HCC post TACE.

Recent advances in imaging techniques of renal masses

Multiphasic multidetector computed tomography(CT)forms the mainstay for the characterization of renal masses whereas magnetic resonance imaging(MRI)acts as a problem-solving tool in some cases.However,a few of the renal masses remain indeterminate even after evaluation by conventional imaging methods.To overcome the deficiency in current imaging techniques,advanced imaging methods have been devised and are being tested.This review will cover the role of contrast-enhanced ultrasonography,shear wave elastography,dual-energy CT,perfusion CT,MR perfusion,diffusion-weighted MRI,blood oxygen leveldependent MRI,MR spectroscopy,positron emission tomography(PET)/prostate-specific membrane antigen-PET in the characterization of renal masses.

经子宫输卵管四维超声造影在女性不孕症中的应用

目的:为了提高临女性不孕症的检出率,分析采用经子宫输卵管四维超声造影的价值和意义。方法:根据接诊顺序从2015年8月至2019年8月在本院治疗的女性不孕症患者中随机选取1714例,其中接受三维超声造影检查的患者857例,接受经子宫输卵管四维超声造影检查的患者857例。作为研究对象并按照随机、双盲、对照原则,其中接受三维超声造影检查的患者设为对照组,接受经子宫输卵管四维超声造影检查的患者设为观察组,比较两组在图像质量优良率、诊断输卵管通畅率等方面的差异。结果:研究数据显示,观察组和对照组患者超声造影图像质量的优良率分别为96.85%(830/857)、84.01%(720/857),与对照组相比观察组超声造影图像质量优良率明显增加(X^2=81.59,P<0.05);观察组和对照组诊断输卵管通畅率分别为96.85%(830/857)、84.01%(720/857),与对照组相比观察组诊断输卵管通畅率(X^2=81.59,P<0.05);观察组和对照组的检查操作时间分别为(13.34±2.55)min和(20.95±4.66)min,与对照组相比观察组的检查操作时间明显缩短且组间比较差异具有统计学意义(P<0.05)。结论:女性不孕症患者采用经子宫输卵管四维超声造影检查,不仅造影图像质量优良,而且能够提高输卵管通畅检出率,缩短检查时间,效果显著,值得临床推广使用。

Contrast enhanced ultrasound of hepatocellular carcinoma

Sonazoid(Daiichi Sankyo,Tokyo,Japan),a secondgeneration of a lipid-stabilized suspension of a perfluorobutane gas microbubble contrast agent,has been used clinically in patients with liver tumors and for harmonic gray-scale ultrasonography(US)in Japan since January 2007.Sonazoid-enhanced US has two phases of contrast enhancement:vascular and late.In the late phase of Sonazoid-enhanced US,we scanned the whole liver using this modality at a low mechanical index(MI)without destroying the microbubbles, and this method allows detection of small viable hepatocellular carcinoma(HCC)lesions which cannot be detected by conventional US as perfusion defects in the late phase.Re-injection of Sonazoid into an HCC lesion which previously showed a perfusion defect in the late phase is useful for confirming blood flow intothe defects.High MI intermittent imaging at 2 frames per second in the late phase is also helpful in differentiation between necrosis and viable hypervascular HCC lesions.Sonazoid-enhanced US by the coded harmonic angio mode at a high MI not only allows clear observation of tumor vessels and tumor enhancement, but also permits automatic scanning with Sonazoidenhanced three dimensional(3D)US.Fusion images combining US with contrast-enhanced CT or contrastenhanced MRI have made it easy to detect typical or atypical HCC lesions.By these methods,Sonazoidenhanced US can characterize liver tumors,grade HCC lesions histologically,recognize HCC dedifferentiation, evaluate the efficacy of ablation therapy or transcatheter arterial embolization,and guide ablation therapy for unresectable HCC.This article reviews the current developments and applications of Sonazoid-enhanced US and Sonazoid-enhanced 3D US for diagnosing and treating hepatic lesions,especially HCC.

Estimation of intra-operator variability in perfusion parameter measurements using DCE-US

AIM:To investigate intra-operator variability of semiquantitative perfusion parameters using dynamic contrast-enhanced ultrasonography(DCE-US),following bolus injections of SonoVue.METHODS:The in vitro experiments were conducted using three in-house sets up based on pumping a fluid through a phantom placed in a water tank.In the in vivo experiments,B16F10 melanoma cells were xenografted to five nude mice.Both in vitro and in vivo,images were acquired following bolus injections of the ultrasound contrast agent SonoVue(Bracco,Milan,Italy) and using a Toshiba Aplio ultrasound scanner connected to a 2.9-5.8 MHz linear transducer(PZT,PLT 604AT probe)(Toshiba,Japan) allowing harmonic imaging("Vascular Recognition Imaging") involving linear raw data.A mathematical model based on the dye-dilution theory was developed by the Gustave Roussy Institute,Villejuif,France and used to evaluate seven perfusion parameters from time-intensity curves.Intra-operator variability analyses were based on determining perfusion parameter coefficients of variation(CV).RESULTS:In vitro,different volumes of SonoVue were tested with the three phantoms:intra-operator variability was found to range from 2.33% to 23.72%.In vivo,experiments were performed on tumor tissues and perfusion parameters exhibited values ranging from 1.48% to 29.97%.In addition,the area under the curve(AUC) and the area under the wash-out(AUWO) were two of the parameters of great interest since throughout in vitro and in vivo experiments their variability was lower than 15.79%.CONCLUSION:AUC and AUWO appear to be the most reliable parameters for assessing tumor perfusion using DCE-US as they exhibited the lowest CV values.

ROBIS工具评价影像学诊断性试验系统评价质量

目的采用ROBIS工具评价影像学诊断性试验系统评价的质量。资料与方法以"诊断性试验、系统评价、Meta分析、diagnos~*test、diagnos~*trial、systematic review、Meta-analysis"为检索词,检索2014年1月1日—2016年12月31日中国生物医学文献数据库、中国知网、万方数据库、Pub Med、Embase以及Cochrane图书馆中收录的相关文献。由2名研究者独立筛选文献和提取信息后,使用ROBIS工具对所纳入文献进行质量评价。结果本研究共纳入文献219篇,其中中文文献93篇、英文文献126篇。亚组分析结果显示,中、英文文献质量差异有统计学意义(P=0.018);中国地区与其他地区文献质量差异有统计学意义(P<0.001);发表年代间质量差异无统计学意义(P=0.34)。ROBIS评价结果显示,低风险文献仅15篇(6.85%),其中中文文献2篇、英文文献13篇。结论影像学诊断性试验2014—2016年公开发表的中、英文诊断性试验系统评价的质量整体较低,其中中文文献及国内学者发表的文献质量与国际文献尚存在差距。该领域系统评价的制订者在今后的研究中应当提前撰写计划书并完善报告,充分获取证据,针对文献筛选、信息提取以及评价原始研究偏倚等方面尽量减小偏倚,并考虑到结果的稳定性,在此基础上进一步提高该领域系统评价的质量。

Mediastinal Tuberculoma Mimicking Malignant Cardiac Tumor:A Case Report

Background:The clinical manifestations of cardiac masses are diverse and lack specifi city.Here we report a cardiac mass detected by transthoracic echocardiography.Multimodality imaging and pathological fi ndings after the operation confi rmed the mass as mediastinal tuberculoma.Case presentation:A 45-year-old male patient was admitted to our hospital reporting chest tightness,weight loss,and dyspnea for 3 months after exercise.Transthoracic echocardiography showed that there were a large number of pericardial effusions and a soft tissue mass measuring 7.7 cm×4.5 cm in the upper mediastinum,which oppressed the right pulmonary artery and accelerated the blood fl ow of the left pulmonary artery.Contrast-enhanced ultrasonography showed degenerative inhomogeneous high enhancement of and an unclear boundary in the mass.Contrast-enhanced chest CT revealed punctate and patchy calcifi cation in and uneven enhancement of the mass and the lymph nodes around the aortic arch.The mass was diagnosed as a malignant mediastinal tumor.Pathological analysis of the mass revealed chronic granulomatous tuberculosis.The symptoms abated signifi cantly after antituberculosis treatment.The patient remained asymptomatic during follow-up.Conclusion:This report presents a rare case of mediastinal tuberculoma mimicking a malignant cardiac tumor.Multimodality imaging should be incorporated for differentiation of cardiac masses.

声像图质量对人工智能辅助诊断系统与人工测量发育性髋关节发育不良患儿生物学指标一致性的影响

目的观察声像图质量对人工智能(AI)辅助诊断系统与人工测量发育性髋关节发育不良(DDH)生物学指标一致性的影响。方法回顾性分析75例DDH及345例非DDH患儿髋关节超声资料,对声像图进行主观评分。于每例选取1幅图像,以熵权法基于140幅(A组,取自25例DDH及115例非DDH)构建评估声像图质量模型,获得DDH相关解剖结构及影响因素的权重,据以将另外280幅(B组,取自50例DDH及230例非DDH)图像质量由高至低分为A、B、C级;分析AI与人工测量B组DDH生物学指标的一致性。结果DDH相关解剖结构及影响因素权重按照髂骨支下缘、髂骨、盂唇、骨缘转折点、股骨头、运动伪影依序下降。B组A级67幅(取自9例DDH及58例非DDH)、B级160幅(取自26例DDH及134例非DDH)、C级53幅(取自15例DDH及38例非DDH);除DDH患儿声像图中的β、股骨头覆盖率(FHC)及股骨头长径外,AI与人工测量DDH其他指标的一致性由高到低均为A级>B级>C级;二者针对DDH患儿声像图的测量结果的一致性高于非DDH。结论髋关节声像图质量影响AI与人工测量DDH生物学指标的一致性;遇声像图质量欠佳时,应重点测量FHC及股骨头径线。

二氧化碳与空气注气在线阵超声内镜扫查胃隆起病变中的比较

[目的]比较线阵超声内镜(EUS)对胃隆起病变扫查中二氧化碳(CO_(2))代替空气注气能否减轻腹部不适,提高EUS图像质量。[方法]:97例患者因胃隆起病变接受EUS扫查,数字表法随机分配到CO_(2)组49例和空气组48例。记录2组患者操作前、操作后1 h和3 h腹部不适的视觉疼痛评分(VAS)。EUS图像质量分为不合格、差、良、优4个等级。[结果]CO_(2)组与空气组术前VAS评分比较差异无统计学意义,CO_(2)组术后1 h、3 h的VAS评分均明显低于空气组,差异均有统计学意义(P=0.000)。析因分析发现CO_(2)组与内镜是否采用镇静方法VAS评分比较无相互作用(P>0.05)。所有患者的EUS图像质量均为优(4分)或良(3分),CO_(2)组EUS图像质量为优者(65.3%,32/49)多于空气组(43.8%,21/48),2组比较P=0.033。[结论]线阵EUS扫查胃隆起性病变中用CO_(2)代替空气注气会减轻腹部不适,并能改善EUS图像质量。