Double contrast-enhanced ultrasonography improves diagnostic accuracy of T staging compared with multi-detector computed tomography in gastric cancer patients

BACKGROUND Gastric cancer(GC)is the most common malignant tumor and ranks third for cancer-related deaths among the worldwide.The disease poses a serious public health problem in China,ranking fifth for incidence and third for mortality.Knowledge of the invasive depth of the tumor is vital to treatment decisions.AIM To evaluate the diagnostic performance of double contrast-enhanced ultrasonography(DCEUS)for preoperative T staging in patients with GC by comparing with multi-detector computed tomography(MDCT).METHODS This single prospective study enrolled patients with GC confirmed by preoperative gastroscopy from July 2021 to March 2023.Patients underwent DCEUS,including ultrasonography(US)and intravenous contrast-enhanced ultrasonography(CEUS),and MDCT examinations for the assessment of preoperative T staging.Features of GC were identified on DCEUS and criteria developed to evaluate T staging according to the 8th edition of AJCC cancer staging manual.The diagnostic performance of DCEUS was evaluated by comparing it with that of MDCT and surgical-pathological findings were considered as the gold standard.RESULTS A total of 229 patients with GC(80 T1,33 T2,59 T3 and 57 T4)were included.Overall accuracies were 86.9%for DCEUS and 61.1%for MDCT(P<0.001).DCEUS was superior to MDCT for T1(92.5%vs 70.0%,P<0.001),T2(72.7%vs 51.5%,P=0.041),T3(86.4%vs 45.8%,P<0.001)and T4(87.7%vs 70.2%,P=0.022)staging of GC.CONCLUSION DCEUS improved the diagnostic accuracy of preoperative T staging in patients with GC compared with MDCT,and constitutes a promising imaging modality for preoperative evaluation of GC to aid individualized treatment decision-making.

Correlation of dynamic contrast-enhanced ultrasonography and the Ki-67 labelling index in pancreatic ductal adenocarcinoma

BACKGROUND Pancreatic ductal adenocarcinoma(PDAC)is a highly malignant and aggressive tumor,and high Ki-67 expression indicates poor histological differentiation and prognosis.Therefore,one of the challenges in diagnosing preoperatively patients with PDAC is predicting the degree of malignancy.Dynamic contrast-enhanced ultrasonography(DCE-US)plays a crucial role in abdominal tumor diagnosis,and can adequately show the microvascular composition within the tumors.However,the relationship between DCE-US and the Ki-67 labelling index remains unclear at the present time.AIM To predict the correlation between Ki-67 expression and the parameters of DCEUS.METHODS Patients with PDAC who underwent DCE-US were retrospectively analyzed.Patients who had received any treatment(radiotherapy or chemotherapy)prior to DCE-US;had incomplete clinical,imaging,or pathologic information;and had poor-quality image analysis were excluded.Correlations between Ki-67 expression and the parameters of DCE-US in patients with PDAC were assessed using Spearman’s rank correlation analysis.The diagnostic performances of these parameters in high Ki-67 expression group were evaluated according to receiver operating characteristic curve.RESULTS Based on the Ki-67 labelling index,30 patients were divided into two groups,i.e.,the high expression group and the low expression group.Among the relative quantitative parameters between the two groups,relative half-decrease time(rHDT),relative peak enhancement,relative wash-in perfusion index and relative wash-in rate were significantly different between two groups(P=0.018,P=0.025,P=0.028,P=0.035,respectively).The DCE-US parameter rHDT was moderately correlated with Ki-67 expression,and rHDT≥1.07 was more helpful in accurately diagnosing high Ki-67 expression,exhibiting a sensitivity and specificity of 53.8%and 94.1%,respectively.CONCLUSION One parameter of DCE-US,rHDT,correlates with high Ki-67 expression.It demonstrates that parameters obtained noninvasively by DCE-US could better predict Ki-67 expression in PDAC preoperatively.

Clinical value of oral contrast-enhanced ultrasonography in diagnosis of gastric tumors

BACKGROUND The incidence of gastric cancer remains high,and it is the sixth most common cancer and the fourth leading cause of cancer deaths worldwide.Oral contrastenhanced ultrasonography is a simple,non-invasive,and painless method for the diagnosis of gastric tumors.AIM To explore the diagnostic value of oral contrast-enhanced ultrasonography for the detection of gastric tumors.METHODS The screening results based on oral contrast-enhanced ultrasonography and electronic gastroscopy were compared with those of the postoperative pathological examination.RESULTS Among 42 patients with gastric tumors enrolled in the study,the diagnostic accordance rate was 95.2%for oral contrast-enhanced ultrasonography(n=40)and 90.5%for electronic gastroscopy(n=38)compared with postoperative pathological examination.The Kappa value of consistency test with pathological findings was 0.812 for oral contrast-enhanced ultrasonography and 0.718 for electronic gastroscopy,and there was no significant difference between them(P=0.397).For the TNM staging of gastric tumors,the accuracy rate of oral contrast enhanced ultrasonography was 81.9%for the overall T staging and 50%,77.8%,100%,and 100%for T1,T2,T3,and T4 staging,respectively.The sensitivity and specificity were both 100%for stages T3 and T4.The diagnostic accuracy rate of oral contrast-enhanced ultrasonography was 93.8%,80%,100%,and 100%for stages N0,N1-N3,M0,and M1,respectively.CONCLUSION The accordance rate of qualitative diagnosis by oral contrast-enhanced ultrasonography is comparable to that of gastroscopy,and it could be used as the preferred method for the early screening of gastric tumors.

Double contrast-enhanced two-dimensional and three-dimensional ultrasonography for evaluation of gastric lesions

AIM： To investigate the value of two-dimensional （2D） and three-dimensional （3D） double contrast-enhanced ultrasonography （DCUS） imaging for evaluation of gas- tric lesions. METHODS： 2D and 3D DCUS imaging with both oral and intravenous administrations of contrast agents was used to assess gastroscopiclly-confirmed gastric lesions in 46 patients with benign and malignant diseases. Initially, liquid-based ultrasound contrast agent （Xinzhang） was given orally at dose of 500-600 mL for conventional ultrasound examination of the gastric lesions, and then a microbubble-based contrast agent （SonoVue） was injected intravenously at dose of 1.2-2.4 mL in bolus fashion to assess the perfusion pattern of the lesions using contrast imaging modes. The parameters derived from time-intensity curves including the arrival time （AT）, time to peak （lq-P）, peak intensity （PI） and en- hanced intensity （EI） were measured on the 2D DCUS imaging. 3D DCUS of the lesions was acquired to dem- onstrate the value of this imaging mode. RESULTS： There were 22 cases with benign lesions including chronic gastritis （n= 5）, gastric ulcer （n = 9）, gastric polyps （n = 3）, gastric stromal tumors （n = 5）, and 24 cases with malignant lesions including gastric cancer （n = 20）, gastric cardia carcinoma （n = 3） and post-operative recurrent gastric cancer （n = 1） in the study, The oral contrast-enhanced ultrasonography （CEUS） imaging of the stomach clearly demonstrated the anatomy of the stomach and morphologic features of gastric lesions, With optimal scanning window and imaging display under oral CEUS, intravenous CEUS clearly showed the perfusion of gastric lesions with various characteristic manifestations. Both 2D and 3D DCUS images clearly demonstrated normal gastric wall as a three-layer structure, from the inside out, hypere- choic mucosa, hypoechoic muscularis and hyperechoic serosa, respectively. There were statistical significant differences of AT （8.68±2.06 vs 10.43 ±2.75, P = 0.017）, PI （34.64 ± 6.63 vs 29.58 ± 8.22, P = 0.023） and EI （29.72 ± 6.69 vs 22.66 ± 7.01, P = 0.001） between malignant lesions and normal gastric wall. However, no differences of AT, PI and EI between benign lesions and normal gastric wall tissue were found. 3D DCUS could intuitively display morphological features and vascularities of the lesions with multiplanar and volume views. 3D DCUS imaging provided comprehen- sive information complementary to 2D imaging. The crater or wellhead appearances and feeding vessels as well as distorted nourishing vasculature of gastric carcinoma were better seen with 3D imaging than 2D imaging. CONCLUSION： DCUS imaging can simultaneouslydisplay the anatomic and perfusion features of gastric lesions. 3D DCUS can provide additional information to 2D DCUS for evaluation of gastric lesions.

Mass-forming pancreatitis: Value of contrast-enhanced ultrasonography

AIM： To assess the utility of contrast-enhanced ultrasonography （CEUS） with a second-generation contrast medium in the differential diagnosis between mass-forming pancreatitis and pancreatic carcinoma. METHODS： From our radio-pathology database, we retrieved all the patients affected by mass-forming pancreatitis or pancreatic carcinoma who underwent CEUS. We evaluated the results of CEUS in the study of the 173 pancreatic masses considering the possibilities of a differential diagnosis between mass-forming pancreatitis and pancreatic tumor by identifying the ＂parenchymographic＂ enhancement during the dynamic phase of CEUS, which was considered diagnostic for mass-forming pancreatitis. RESULTS： At CEUS, 94% of the mass-forming pancreatitis showed intralesional parenchymography. CEUS allowed diagnosis of mass-forming pancreatitis with sensitivity of 88.6%, specificity of 97.8%, positive predictive value of 91.2%, negative predictive value of 97.1%, and overall accuracy of 96%. CEUS significantly increased the diagnostic confidence in the differential diagnosis between mass-forming pancreatitis and pancreatic carcinoma, with receiver operating characteristic curve areas from 0.557 （P = 0.1608） for baseline US to 0.956 （P 〈 0.0001） for CEUS. CONCLUSION： CEUS allowed diagnosis of massforming pancreatitis with diagnostic accuracy of 96%. CEUS significantly increases the diagnostic confidence with respect to basal US in discerning mass-forming pancreatitis from pancreatic neoplasm.

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 peripheral lung consolidations: What's its actual role?

AIM:To evaluate the diagnostic accuracy of contrastenhanced ultrasonography(CEUS)in the differential diagnosis between neoplastic and non-neoplastic peripheral pleuro-pulmonary lesions.METHODS:One hundred patients with pleural or peripheral pulmonary lesions underwent thoracic CEUS.An 8 microliters/mL solution of sulfur hexafluoride microbubbles stabilized by a phospholipid shell(SonoVue)was used as US contrast agent.The clips were stored and independently reviewed by two readers,who recorded the following parameters:presence/absence of arterial enhancement,time to enhancement(TE),extent of enhancement(EE),pattern of enhancement(PE),presence/absence of wash-out,time to wash-out,and extent of wash-out.After the final diagnosis(based on histopathologic findings or follow-up of at least 15 mo)was reached,sensitivity,specificity,positive predictive value(PPV),negative predictive value(NPV),positive likelihood ratio(PLR),negative likelihood ratio(NLR)of each CEUS parameter in the differential diagnosis between neoplastic and nonneoplastic lesions were calculated.Furthermore,an arbitrary score based on the ratio between the PPVs of each CEUS parameter was calculated,to evaluate if some relationship could exist between overall CEUS behaviour and neoplastic or non-neoplastic nature of the lesions.

Differentiation of focal liver lesions using three-dimensional ultrasonography: Retrospective and prospective studies

AIM: To differentiate focal liver lesions based on enhancement patterns using three-dimensional ultrasonography (3D US) with perflubutane-based contrast agent.METHODS: Two hundred and eighty two patients with focal liver lesions,including 168 hepatocellular carcinomas (HCCs),63 metastases,40 hemangiomas and 11 focal nodular hyperplasias (FNHs),were examined by 3D US with perflubutane-based contrast agent.Tomographic ultrasound images and sonographic angiograms were reconstructed.Among 282 lesions,enhancement patterns of 163 lesions between January 2007 and October 2007 were analyzed retrospectively.Then from November 2007 to May 2008,compared with contrast-enhanced (CE) 2D US,CE 3D US was performed on 119 lesions for prospective differential diagnosis.Sensitivity,specificity,area under receiver operating characteristic curve (Az) and inter-reader agreement were assessed.RESULTS: With the tridimensional view,dominant enhancement patterns were revealed as diffuse enhancement or peripheral ring-like enhancement,followed with washout change for HCCs or metastases,respectively,and peripheral nodular enhancement or diffuse enhancement with spoke-wheel arteries,followed by persistent enhancement for hemangiomas or FNHs,respectively.At CE 3D US,the prospective differentiation of lesions showed sensitivity 92% (mean for two readers),specificity 91% and Az value 0.95 for HCCs,84%,97%,and 0.95 for metastases,91%,98%,and 0.98 for hemangiomas and 80%,99%,and 0.99 for FNHs,respectively,while good to excellent inter-reader agreement was achieved.No significant difference exists between prospective diagnosis accuracy at CE 3D US and that at CE 2D US.CONCLUSION: CE 3D US provides a spatial perspective for liver tumor enhancement,and could help in differentiating focal liver lesions.

Efficacy of intra-arterial contrast-enhanced ultrasonography during transarterial chemoembolization with drug-eluting beads for hepatocellular carcinoma

AIM To assess the usefulness of intra-arterial contrastenhanced ultrasonography(IAUS) during transarterial chemoembolization(TACE) with drug-eluting beads(DEB) for hepatocellular carcinoma(HCC).METHODS Thirty two patients with 39 HCC underwent DEB-TACE guided with IAUS, and examined by contrast-enhanced ultrasonography(CEUS) or dynamic CT after DEB-TACE were enrolled in this study. CEUS findings before DEBTACE and IAUS findings were compared. Treatments judged to be complete and incomplete for lesions were appropriate and insufficient, respectively. Findings on CEUS and/or dynamic CT performed 1, 3 and 6 mo after DEB-TACE were evaluated using m RECIST(CR/PR/SD/PD).RESULTS The treatments were complete and incomplete in 26 and 13 lesions, respectively. On imaging evaluation using CEUS and/or dynamic CT one month after treatment, 25 and 1 lesions were judged to be CR and PR, respectively, and at 6 mo after treatment, the results were CR, PR, SD and PD for 24, 1, 0 and 1 of these lesions, respectively, in the 26 completely treated lesions. Of the 13 lesions in which treatment was incomplete, the results on imaging at one month after treatment were CR, PR, SD and PD for 0, 6, 4 and 3 lesions, respectively. The overall CR rate at 6 mo after treatment was 61.5%(24/39).CONCLUSION A combination of DEB-TACE with IAUS can improve the therapeutic effects in patients with HCC.

Clinical value of contrast-enhanced ultrasonography in the characterization of focal liver lesions:a prospective multicenter trial

BACKGROUND: Contrast-enhanced ultrasonography (CEUS) is increasingly accepted in clinical settings for diagnostic imaging of focal liver lesions (FLLs). This study aimed to assess the efficacy of CEUS in the characterization of FLLs in comparison with final diagnosis based on gold standard assessment. METHODS: The study was approved by the local ethics committee and participating patients provided written informed consent. A total of 148 patients with 164 FLLs were studied. Unenhanced ultrasonography (US) and CEUS were performed using fundamental and harmonic imaging, respectively. Contrast enhancement was assessed during the arterial, portal and late vascular phases after intravenous administration of contrast (SonoVue (R), Bracco, Italy). Sensitivity, specificity and diagnostic accuracy of US and CEUS were compared in identifying the lesion as benign, malignant or indeterminate and its actual tumor type. Final diagnosis was established by biopsy (129/164), MR imaging (11/164) or medical history (24/164). RESULTS: When compared to the gold standard, the number of indeterminate diagnoses was reduced from 56.7% (93/164) as assessed by fundamental imaging to 6.1% (10/164) after SonoVue (R) enhanced US examination. Sensitivity and specificity improved from 49% and 25% at baseline US to 93% and 75% with CEUS, respectively (P<0.01). Diagnostic accuracy of CEUS was 88% in contrast to 41% of baseline US. CONCLUSION: SonoVue (R) enhanced US improves the characterization of FLLs and may limit the need for further investigations.

Arterial-phase contrast-enhanced ultrasonography for evaluating anti-angiogenesis treatment: A pilot study

AIM:To verify whether arterial-phase contrast-enhanced ultrasonography(CEUS) of tumor parenchymal tissue is useful for evaluation of anti-angiogenesis agents.METHODS:Rabbits with liver tumor were subjected to CEUS,and images of the nodular maximal diameter in vascular phase were recorded.Image analysis was performed to plot the time intensity curve(TIC) at the tumor parenchyma,which set the diameter of the region of interest of intensity measurement.The TIC was calculated to obtain the time to peak intensity(TPI) and the magnitude of PI.Rabbits were randomly assigned to a treatment group with sorafenib and a control group.Two weeks later,the same ultrasound examination was repeated followed by pathological testing to assess the effect of sorafenib on the liver tumor.RESULTS:In four rabbits in the treatment group,the rate of change of tumor size was decreased comparedwith that of the control(the rate 2.3 vs 7.9,P = 0.02).The TPI of the treatment group elongated significantly(the rate 3.1 vs 1.1,P = 0.07 for SonoVue,2.0 vs 0.88,P = 0.09 for Sonazoid).The magnitude of PI showed no significant changes.In pathological examination,capillary diameters in the treatment group were significantly smaller than those in the control group(26.4 vs 42.8 μm,P = 0.013).CONCLUSION:Analysis of the TIC in the arterial phase of tumor tissue could evaluate the efficacy of antiangiogenesis drug treatment in liver tumor.

Contrast-enhanced intraoperative ultrasonography equipped with late Kupffer-phase image obtained by sonazoid in patients with colorectal liver metastases

AIM: To find occult metastases during hepatectomy in patients with colorectal cancer liver metastases (CRCLM), contrast-enhanced intraoperative ultrasonography (CE-IOUS) was performed using a new microbubble agent, sonazoid, which provides a parenchyma-specific contrast image based on its accumulation in the Kupffer cells. METHODS: Eight patients with CRCLM underwent CE- IOUS using sonazoid before hepatectomy. The liver was investigated during a late Kupffer-phase imaging, which is a valuable characteristic of sonazoid. RESULTS: CE-IOUS using sonazoid provided the early vascular- and sinusoidal-phase images for 10 min followed by the late Kupffer-phase image up to 30 min after the injection of sonazoid. IOUS did not provide new findings of metastatic lesion in the 8 patients. However, during the late Kupffer-phase image of sonazoid, a metastatic lesion was newly found in two of the 8 patients. These newly detected lesions were removed by an additional hepatectomy and histopathologically diagnosed as a metastasis. CONCLUSION: CE-IOUS using sonazoid can allow surgeons to investigate the whole liver with enough time and to find new metastases intraoperatively.

Evaluation of hepatocellular carcinoma using contrast-enhanced ultrasonography:correlation with microvessel morphology

BACKGROUND: Contrast-enhanced ultrasonography (CEUS) is an important technique for depiction and assessment of tumor vascularity. This study aimed to explore the relationship between the morphological characteristics of tumor microvessels and enhancement patterns on CEUS in hepatocellular carcinoma (HCC). METHODS: Eighty patients with HCC underwent CEUS using SonoVue before hepatectomy. Contrast-enhanced ultrasonographic enhancement patterns and quantitative parameters were recorded. The tumor tissue sections were immunostained with human CD34 monoclonal antibody. The patients were classified into a point-line type group (n=36) and a loop-strip type group (n=44) according to microvessel morphology. The microvascular density (MVD) in the different types of microvessels was calculated. The relationship between enhancement patterns of HCC lesions and morphological characteristics of tumor microvessels was analyzed. RESULTS:TS: The mean MVD in HCC was 22.4 +/- 3.5 per 0.2 mm(2) in the point-line group, and 19.6 +/- 6.7 per 0.2 mm(2) in the loop-strip group, and there was no significant difference between them (t=0.948, P=0.354). In the portal vein phase, hypoenhancement was significantly more frequent in HCC (chi(2)=4.789, P=0.029) in the loop-strip group (40/44, 90.9%) than in the point-line group (26/36, 72.2%). The time to hypoenhancement in the loop-strip group (mean 64.84 +/- 26.16 seconds) was shorter than that in the point-line group (mean 78.39 +/- 28.72 seconds) (t=2.247, P=0.022). The time to hypoenhancement was correlated with MVD in the loop-strip group (r=-0.648, P=0.001). CONCLUSIONS: The enhancement patterns on CEUS are related to tumor microvascular morphology, and the type of microvascular morphology influences CEUS characterization. CEUS, an important noninvasive imaging technique, is used to evaluate microvascular morphology and angiogenesis, providing valuable information for antiangiogenic therapy in HCC. (Hepatobiliary Pancreat Dis Jut 2010; 9:605-610)

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.

Role of ultrasonography and contrast-enhanced ultrasonography in a case of Krukenberg tumor

We report a case of Krukenberg tumor of gastric origin with adnexal metastasis,in which ultrasonography(US) and contrast-enhanced US(CEUS) played a key diagnostic role.An 64-year-old female patient was referred to our department for abdominal pain,nausea and ascites.US examination was performed as first line diagnostic imaging approach,confirming the presence of ascites and detecting marked thickness of the gastric wall and a right adnexal mass.CEUS was immediately performed and showed arterial enhancement followed by wash-out in the venous phase of both the gastric wall and the adnexal mass,suggesting the diagnosis of gastric cancer with right adnexal metastasis(Krukenberg syndrome).The patient underwent USguided paracentesis and esophagogastroduodenoscopy that showed linitis plastica.Cytologic examination of the peritoneal fluid revealed the presence of signetring cells,and histologic examination of the specimen obtained by endoscopic biopsy showed primary gastric mucus-producing adenocarcinoma with signetring cells.Although transvaginal US is undoubtedly the method of choice to evaluate ovarian tumors,abdominal US and CEUS can provide key diagnostic elements,supporting clinicians in the first steps of the diagnostic work-up of abdominal and pelvic masses.

Contrast-enhanced harmonic endoscopic ultrasonography for assessment of lymph node metastases in pancreatobiliary carcinoma

AIM: To assess the usefulness of contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) for lymph node metastasis in pancreatobiliary carcinoma.METHODS: All patients suspected of pancreatobiliary carcinoma with visible lymph nodes after standard EUS between June, 2009 and January, 2012 were enrolled. In the primary analysis, patients with successful EUS-fine needle aspiration (FNA) were included. The lymph nodes were assessed by several standard EUS variables (short and long axis lengths, shape, edge characteristic and echogenicity), color Doppler EUS variable [central intranodal blood vessel (CIV) presence] and CH-EUS variable (heterogeneous/homogeneous enhancement patterns). The diagnostic accuracy relative to EUS-FNA was calculated. In the second analysis, N-stage diagnostic accuracy of CH-EUS was compared with EUS-FNA in patients who underwent surgical resection.RESULTS: One hundred and nine patients (143 lymph nodes) fulfilled the criteria. The short axis cut-off &#x02265; 13 mm predicted malignancy with a sensitivity and specificity of 72% and 85%, respectively. These values were 72% and 63% for the long axis cut-off &#x02265; 20 mm, 62% and 75% for the round shape variable, 81% and 30% for the sharp edge variable, 66% and 61% for the hypoechogenicity variable, 70% and 72% for the CIV-absent variable, and 83% and 91% for the heterogeneous CH-EUS-enhancement variable, respectively. CH-EUS was more accurate than standard and color Doppler EUS, except the short axis cut-off. Notably, three patients excluded because of EUS-FNA failure were correctly N-staged by CH-EUS.CONCLUSION: CH-EUS complements standard and color Doppler EUS and EUS-FNA for assessment of lymph node metastases.

Evaluation of Carotid Plaque Neovascularization in Patients with Diabetes Mellitus by Contrast-enhanced Ultrasonography

This study investigated the relationship between carotid plaque neovascularization and diabetes mellitus（DM） by using contrast-enhanced ultrasonography. Contrast-enhanced ultrasonography was performed in 104 patients with carotid plaque thicker than 2.0 mm. There were 36 patients with DM and 68 patients without DM. The enhanced intensity in the plaque and the ratio of enhanced intensity in the plaque to that in the lumen of the carotid artery in patients with DM were significantly greater than those in patients without DM. Our study demonstrated that the enhanced intensity in patients with DM is greater than that their counterparts without DM, suggesting that carotid plaque in DM patients may have more neovessels and may be more vulnerable.

Correlation between Enhanced Intensity of Atherosclerotic Plaque at Contrast-enhanced Ultrasonography and Density of Histological Neovascularization

Summary： The feasibility of contrast-enhanced ultrasonography in the assessment of atherosclerotic plaque neovascularization and its relation to histological findings were investigated. Abdominal aortic atherosclerotic plaque model was induced in 25 New Zealand white rabbits by a combination of high cholesterol-rich diet and balloon aortic denudation. Standard and contrast-enhanced ultrasonography was performed at the 16th week of the model induction period. The plaques were classified as echogenic plaques or echolucent plaques according to their echogenicity at standard ultrasonography. The maxi- mum thickness of plaque was measured in the longitudinal section. Time intensity curve was used to quantify the enhanced intensity of the plaque. Animals were euthanized and abdominal aortas were har- vested for histological staining of CD31 to evaluate the neovascularization density of atherosclerotic plaque. The results showed that the echolucent plaques had higher enhanced intensity during con- trast-enhanced ultrasonography and higher neovascularization density at CD31 staining than the echo- genic plaques. The enhanced intensity of atherosclerotic plaque and its ratio to lumen were well corre- lated with histological neovascularization density （r=0.75, P〈0.001; r=0.68, P〈0.001, respectively）. However, the maximum thickness of plaque was not correlated with neovascularization density （r=0.235, P=0.081）. These findings demonstrated that the enhanced intensity in the plaque and ratio of enhanced intensity to that in the lumen of abdominal aorta may be more accurate in the evaluation of plaque neovascularization than maximum thickness. Our study indicates that contrast-enhanced ultra- sonography provides us a reliable method for the evaluation of plaque neovascularization.

Usefulness of contrast-enhanced ultrasonography in determining treatment efficacy and outcome after pancreatic cancer chemotherapy

AIM:To investigate if contrast-enhanced ultrasonography(CE-US) is useful for determining treatment efficacy and outcome in the early stages of pancreatic cancer chemotherapy by assessing changes in intratumor hemodynamics using CE-US with a contrast agent.METHODS:The subjects were 34 patients with unresectable advanced pancreatic cancer treated by chemotherapy.CE-US was assessed after every treatment(course) completion under the same conditions,and patients were divided into two groups according to the intratumor enhancement pattern:Vascular rich(R) group and vascular poor(P) group.RESULTS:After the second course of treatment,R group in intratumor hemodynamics had 18 patients,and P group had 16 patients.The reduction rates of serum CA19-9 level after chemotherapy which decreased to half or less of the baseline level were 2/15(0.1%) in P group,but 11/16(69%) in R group(P = 0.006).When the mean number of courses of chemotherapy and outcome were compared,P group had a mean number of courses of 4.9(R group,10.2) and mean survival time(MST) of 246 d(R group,402 d),showing that outcome was significantly better in R group(P=0.006).CONCLUSION:CE-US revealed that the change in intratumor blood flow correlated with both serum CA19-9 level and outcome.Patients with serum CA19-9 that decreased to less than half the baseline level,and patients with an abundant intratumor blood flow,had a significantly better outcome.Thus,CE-US is potentially useful for evaluating treatment efficacy and outcome in the early stages of pancreatic cancer chemotherapy.

Contrast-enhanced ultrasonographic findings of serum amyloid A-positive hepatocellular neoplasm: Does hepatocellular adenoma arise in cirrhotic liver?

Hepatocellular adenoma(HCA) was recently classified into four pathological subtypes. There have been few studies describing the findings of contrast-enhanced ultrasonography(CEUS) of each type. Our case concerns a 78-year-old man who had undergone routine medical check-ups for hepatitis C for 11 years. Abdominal ultrasonography showed a 28 mm, hypo-echoic mass in the segment 4 of the liver. His integrating amount of drinking was 670 kg convert into ethanol. CEUS with Sonazoid demonstrated mild uniform hypo-enhancement with inflow of microbubbles from the periphery of the tumor in the arterial phase, and heterogeneously hypo-enhancement in the post vascular phase. Because the mass increased in size within 3 mo, a well differentiated hepatocellular carcinoma was suspected, and hepatic resection was performed. Microscopic findings showed homogeneous cell proliferation with low grade atypia, infiltration of inflammatory cells, ductular reactions, fatty deposit in part, and sinusoidal dilation. Immunohistochemistry revealed geographic positive for serum amyloid A(SAA), focal positive for glutaminesynthetase, diffuse and strong positive for C-reactive protein, and positive for liver-type fatty acid binding protein. These pathological features corresponded to that of an inflammatory HCA. However, we could not make a clear diagnosis, because HCAs were defined as not to arise in cirrhotic liver. Finally, this tumor was diagnosed as a SAA positive hepatocellular neoplasm.