Differential Diagnosis Of Focal Lesions Research Articles

Double inferior vena cava with bilateral mild hydronephrosis: a rare case report

A 47-year-old female with a history of antiphospholipid syndrome and ischemic stroke was presented to the emergency department due to abdominal pain and bloody vomiting. Ultrasonography showed double inferior vena cava and bilateral mild hydronephrosis. Furthermore, the abdominal computed tomography (CT) scan did not show any evidence of urolithiasis. The ultrasound images of distinctive developmental variations of inferior vena cava and other veins are important to be known. Vascular anomalies, although rare, should be taken into account in the differential diagnosis of focal lesions within the abdominal cavity. Double IVC might have been the cause of hydronephrosis in our patient.

Ultrasound Elastography--Review of Techniques and Its Clinical Applications in Pediatrics--Part 1.

Sonoelastography is anovel technique that uses ultrasound waves to assess the elasticity of tissues noninvasively. It provides an ultrasound-based method to detect and display the relative stiffness of tissue. The main principle of sonoelastography is the measurement of tissue distortion in response to external compression. Changes in elasticity and tissue deformation elicited by compression are measured, processed and then shown in real time presentation with color-coded elastograms. One of the most important applications of sonoelastography is the evaluation of liver diseases, mainly liver fibrosis assessment and staging. Although in terms of definite diagnosis the liver biopsy still remains the golden standard, elastography seems to be avery inexpensive, repeatable and noninvasive method to evaluate most of liver conditions. The technique is also applicable in detection and differential diagnosis of focal lesions. It provides better imaging information and therefore more accurate evaluation of the lesions nature, e.g. in liver, lymphatic nodes or thyroid gland. Most of the applications mentioned above are well known and have been described in details in adults. Similarly, most of sonoelastographic studies are based on groups of adults. The purpose of this review article is to bring this technology closer to pediatric clinicians and to summarize some of its current clinical applications that are being pursued. In this part we focus on utility of elastography in liver assessment in pediatric patients.

Ocena przydatności obrazowania dyfuzji metodą rezonansu magnetycznego w diagnostyce różnicowej łagodnych i złośliwych zmian ogniskowych w wątrobie

Introduction. Despite the use of multiple diagnostic imaging techniques, a non-invasive differential diagnosis of focal lesions in the liver is still a challenging task. It is even more significant, considering the risk of complications related to liver biopsy. On the other hand, the availability of non-invasive radiological and diagnostic imaging methods has resulted in the increased detectability of incidental hepatic lesions. Therefore, further investigation of newer and more effective methods of differentiating benign from malignant hepatic lesions is extremely useful. The aim of the study was to assess the diagnostic value of Diffusion-Weighted Magnetic Resonance Imaging (DW MRI) in differentiating benign from malignant focal lesions in the liver. Material and methods. Fifty one patients with hepatic lesions detected by magnetic resonance (MR) examination were enrolled in the study. Each lesion was then verified histopathologically, cytologically, or by observation. Ninety five (71 malignant and 24 benign) hepatic focal lesions were analysed. Apart from a standard MR liver examination, an echo planar imaging spin echo diffusion weighted sequence was performed, with a slice thickness of 5 or 6 mm. The maximal b-value was 1000 s/mm 2 and the minimal 0 s/mm 2 .In the study, the following were assessed: the presence of restricted diffusion, an absolute ADC (apparent diffusion coefficient) value, the decrease of signal intensity in DW MRI with an increase in the b-value. Results. Confirming or ruling out the restricted diffusion is usually the first effective step in differentiating benign from malignant hepatic lesions, as indicated in the study results. In the material analysed, the diffusion restriction occurred statistically significantly more frequently in malignant (87.3 %) compared to benign lesions (12.5%), (p 1.04 × 10 -3 mm2/s to be benign and lesions with ADC value ≤ 1.04 × 10 -3 mm 2 /s to be malignant, 75.8% lesions were correctly classified. Conclusions. The results obtained indicate that restricted diffusion, as a marker for malignant lesions, has the highest value in DW MRI in differentiating benign from malignant lesions in the liver.

Errors and mistakes in the ultrasound diagnosis of the pancreas.

The differential diagnosis of the focal lesions in the region of the pancreas is difficult due to the similarity of clinical and radiological pictures of neoplastic and non-neoplastic lesions. This paper presents the most common causes of errors in ultrasound diagnosis of pancreatic pathologies. Attention was paid to the errors resulting from the structural variants of the pancreas and those caused by the neighborhood of intestine, stomach and other organs or vessels. Moreover, the article presents mistakes in the interpretation of ultrasound images of normal pancreas as well as its inflammatory and neoplastic lesions. The errors and mistakes in question were divided into three categories: 1) mistakes related to the anatomical structure of the pancreas (anatomical variants, echostructure and echogenicity, course of the splenic artery); 2) mistakes related to anatomical structures localized in the vicinity of the pancreas (caudate lobe of the liver, other organs and intestinal loops surrounding the head of the pancreas, vessels and bile ducts, lymph nodes in the region of the pancreas or duodenal diverticula and tumors); 3) mistakes related to the pathologies of the pancreas (inflammatory and neoplastic lesions including differentiation between inflammatory tumors and malignant masses). In spite of the progress of imaging techniques, the differential diagnosis of focal solid lesions remains the prime problem of imaging examinations of the pancreas. The major aim of the ultrasound examination is early detection of pancreatic neoplasm. Improper performance of the examination or a failure to perform a repeated scan when the conditions for the assessment of the pancreas are not favorable or, what is worse, description of normal pancreas when it is not clearly and entirely visible, constitute errors.

Mo1678 Classification of Indeterminate Pancreaticobiliary Strictures Pre- and Post-Biliary Stenting by Probe-Based Confocal LASER Endomicroscopy

transit time (MTT). The findings were compared with pathological/cytological results or long time of follow up. Results: To eliminate patient and exam-related factors, such as interactions of the contrast agent with anticoagulants, stenoses in vessels, and changes in heart rate and heart time volume, etc. CH-EUS was performed in 26 patients with a solid lesion in pancreas (16 carcinomas, 9 chronic pancreatitis, and 1 solid pseudopapillary tumor) with certain pathological/cytological results or follow up over 2 years and 5 patients with normal pancreas. Accordingly, for subsequent analyses, only the differences between the lesion and the normal pancreatic tissue of each patient were used. In CH-EUS, the malignant tumor was relatively hypointense compared to the surrounding pancreatic tissue, resulting in consistently positive values in difference of IMAX( IMAX IMAXnormal-IMAXtumor). The TTP was, on average, 36 seconds longer in PDACs than in the normal tissue, while in CP the TTP was similar or only a few seconds longer than in the normal tissue. And the RT in cancerous lesions was significantly longer than in healthy pancreas and non-cancerous lesions. With the use of quantification software, as in our study, this visual impression can thus be detected and measured with a sensitivity that is unachievable with subjective visual impressions alone. Conclusions: Contrast quantification software supplements a subjective visual assessment with objective criteria to facilitate the differential diagnosis of focal lesions in pancreatic cancer and non-cancerous lesions of pancreas, and needs further investigation. Values of the Characteristic Parameters of the Time-Intensity Curve Measured in the Normal Pancreas, and in suspicious lesions of pancreatic cancer, chronic pancreatitis, and SPPT of the pancreas

Contrast-Enhanced Transrectal Ultrasound for Differential Diagnosis of Focal Pathology of Prostate: Single-Center Retrospective Comparative Study

Background. Prostate cancer is a frequently diagnosed malignant disease in men. At present transrectal ultrasound is the most common technique for imaging the gland. Traditionally, a combination of grayscale and Doppler modes is used. In order to make transrectal ultrasound of the prostate more informative, the contrast-enhanced techniques are recommended to apply. Contrast-enhanced ultrasound can provide quantitative assessment, which, in turn, increases the objectivity of the results obtained.Objective. To evaluate potential of contrast-enhanced transrectal ultrasound for differential diagnosis of focal pathology of the prostate.Methods. A single-center retrospective comparative study of contrast-enhanced transrectal ultrasound of the prostate gland in 66 patients was carried out at the Republican Clinical Oncological Dispansery, the Republic of Tatarstan. The inclusion criteria was the presence of focal pathology in the peripheral zone of the prostate gland. The median age of patients was 67. The following quantitative perfusion parameters were analyzed: time to peak, peak intensity, descending time, area under the curve and an additional index calculated for each of the specified parameters. The resulting enhancement curves were also analyzed by measuring enhancement angles (β) and washout angles (α). SPSS 13.0 (IBM SPSS Statistics, USA) was used for data analysis.Results. The combination of “angle ß ≥69.5°+ angle α≤69.5°” with sensitivity of 92.7%, specificity 80.0% proved to be the most informative. The sensitivity and specificity of the obtained threshold values “enhancement angle ß≥69.5°” comprised 73.2% and 60.0%, respectively, “washout angle α≤69.5°” — 63.4% and 56.0%, respectively. According to the analysis of perfusion quantitative parameters the test “peak intensity ≥ 34.1 dB” with sensitivity of 75.6%, specificity of 84.0% has the most informative value in the diagnosis of prostate cancer.Conclusion. Quantitative analysis of contrast-enhanced transrectal ultrasound of the prostate gland provides objectification of the study, and the use of threshold values increases the informativity in the differential diagnosis of focal lesions of the prostate gland.

Diffusion-weighted imaging of the liver: usefulness of ADC values in the differential diagnosis of focal lesions and effect of ROI methods on ADC measurements

By measuring the apparent diffusion coefficient (ADC) of liver parenchyma and focal hepatic lesions (FHL) we proposed to investigate the utility of ADC in the differential diagnosis of hepatic disease and to determine the influence of region of interest (ROI) characteristics in those measurements. Ninety-three patients with at least one supracentimetric FHL, or parenchymal abnormality, were retrospectively evaluated. Diagnosis was based on histopathologic data or, alternatively, on a combination of consensus between imaging methods and 24months of follow-up. Ninety lesions were evaluated with respiratory-triggered diffusion-weighted imaging (b values: 50 and 700s/mm(2)): 14 hepatocellular carcinomas, 18 metastases, 10 focal nodular hyperplasias, four adenomas, 30 hemangiomas and 14 cysts. ADC of hepatic parenchyma was measured by placing ROIs in four different segments, and in FHLs by using three circular 1cm(2) ROIs and one ROI encompassing the full lesion. Data was statistically analyzed (p<0.05 considered significant), and a receiver operating characteristic curve was assessed to evaluate the accuracy for the diagnosis of malignancy. Our measurements showed that parenchyma ADC was significantly higher in segment II and that ADCs of malignant lesions were significantly lower than those of benign lesions (p<0.001). There was significant overlap between benign solid lesions and malignant lesions and the area under the curve for malignancy was 0.939 (sensitivity 89.7%, specificity 90.6%), using a cutoff of 1.43×10(-3) mm(2)/s. No significant difference was found between ROIs of different characteristics. ADC measurements can help to characterize FHLs and differentiate normal from pathological parenchyma. Any ROI above 1cm(2) can provide accurate ADC measurements in homogenous lesions.

Value of ultrasound elastography in diagnosis of focal lesions in the parotid and submandibular glands

Objective To evaluate the applicative value of ultrasound elastography in diagnosis of focal lesions in the parotid and submandibular glands.Methods 30 patients(30 lesions) were scanned by real-time ultrasound elastography and were analyzed in elastography evaluated criteria (5 score method).All the results were compared with the pathological types.Results The elastographic grades of most benign nodules were 1 - 3,while most of malignancy were 4 - 5.The elastographic grades of benign and malignant lesions were of significant difference statistically( P ＜0.01 ).If elastographic grade 4 or 5 were diagnosed as malignancies,the sensitivity,specificity and accuracy for diagnosing malignant l(e)sions in the parotid and submandibular glands were 72.73 ％,84.21 ％,80.00 ％,respectively.Conclusions Ultrasound elastography is useful in the differential diagnosis of focal lesions in the parotid and submandibular glands. Key words: Ultrasonography; Salivary gland neoplasms; Elastography

Sonography of the Spleen

This pictorial essay will review and discuss the aspects of differential diagnosis with splenic sonography, including recent literature and exemplary pictorial sonographic cases. Although the spleen is well evaluated by computed tomography and magnetic resonance imaging, sonography has certain advantages, including its ubiquitous availability, lack of ionizing radiation, and low cost. Sonography of the spleen plays an important role in emergency diagnosis of splenic rupture and hemorrhage. The additional use of contrast-enhanced sonography can improve the diagnostic validity. Depending on the indication, sonography of the spleen is especially important for oncologic differential diagnosis of focal lesions, follow-up examinations, and image guidance of therapeutic interventions.

Magnifying endoscopy with narrow-band imaging for early gastric cancer diagnosis

Objective To evaluate magnifying endoscopy combined with narrow-band imaging （ ME- NBI） for diagnosis of early gastric cancer （EGC）. Methods A total of 150 focal lesions from 143 patients over 35 years old identified by white light endoscopy （WLE） from March 2010 to December 2010 in our tertiary referential institution were recruited in the prospective study with written informed consent. Focal lesions were defined as any small local mucosa with abnormal shape or color based on an assessment of findings of WLE without any specified criteria, including superficial, depressed and elevated lesions. The patients with local advanced gastric cancer, submucosal lesions and history of gastrectomy were excluded from the study. All the patients received ME-NBI. Based on literature, national criteria of early diagnosis with ME- NBI were established. All the lesions underwent biopsy and pathological examination. Diagnostic accuracy of ME-NBI for EGC was assessed with reference to histopathology. Results In 150 focal lesions, 19 were pathologically diagnosed as EGC, 8 of which were treated by endoscopic resection and 11 were resected surgically. The sensitivity, specificity, positive predictive value （pPV）, negative predictive value （NPV） and accuracy of conventional WLE for diagnosing EGC were 94. 7%, 53.4%, 22. 8%, 98.6% and 58.7%, respectively. The counterparts of ME-NBI for diagnosing EGC were 73.7%, 99. 2%, 93.3% , 96. 3% and 96. 0%, respectively. The diagnostic accuracy of ME-NBI was significantly better than that of conventional WLE （96.0% vs. 58. 7%, P 〈0.05）. With regard to the findings of EGC on ME-NBI, irregular or absent microsurface pattern and mierovascular pattern were characteristic features of EGC. Conclusion Conventional WLE is still an important and mandatory screening modality, which is significant for further procedures of suspected lesions, preferably accompanied with biopsy. ME-NBI achieved superior accuracy in the differential diagnosis of focal lesions detected with conventional WLE, but needs further verification. Key words: Early diagnosis; Stomach neoplasms; Magnifying endoscopy; Narrow-band imaging

Quantitative Perfusion Analysis of Transabdominal Contrast-Enhanced Ultrasonography of Pancreatic Masses and Carcinomas

Preoperative differential diagnosis of pancreatic ductal adenocarcinoma (PDAC) and focal masses in patients with chronic pancreatitis (CP) can be challenging. There are fine differences in the vascularization of these lesions; ultrasound contrast agents can aid in their differentiation. We evaluated the value of software-aided quantitative analysis of transabdominal contrast-enhanced ultrasonography for differential diagnosis of PDAC vs focal masses. Sixty patients for whom it was not possible to differentiate between an inflammatory focal lesion of the pancreas and a pancreatic carcinoma underwent contrast-enhanced ultrasonography with a second-generation contrast agent. Time-intensity curves were obtained for all exams in 2 regions of interest within the lesion and within the normal pancreatic tissue. Images were processed using Axius ACQ software; the following parameters were obtained: maximum intensity, arrival time, time-to-peak, and area under the curve. Absolute values and differences between the lesion and the normal tissue were evaluated. Histology analysis revealed 45 PDACs and 15 inflammatory masses in patients with CP. Time-dependent parameters (arrival time and time to peak) were significantly longer in PDACs compared to focal masses. Although markedly lower than in healthy pancreata, the maximum intensity and area under the curve parameters were not significantly different between PDACs and focal lesions in patients with CP. In cases of CP, PDAC and focal masses exhibit different perfusion patterns at a capillary level that can be visualized using the small microbubbles of ultrasound contrast agents. Contrast quantification software supplements a subjective visual assessment with objective criteria to facilitate the differential diagnosis of focal lesions in pancreatic cancer and chronic pancreatitis.

Magnetoresonance tomography in differential diagnosis of focal lesions of the liver

The importance of magnetoresonance tomography among noninvasive methods of visualization of Ca liver and diagnosis of focal lesions is noted. The method under discussion is highly sensitive (100%) in diagnosis of the liver cysts with minimum diameter (6 mm). Its specificity without the use of contrasting reagents averages 92%.