Ultrasound Surveillance Research Articles

Sex-dependent influence of maternal predictors on fetal anthropometry in pregnancies with gestational diabetes mellitus

BackgroundThird trimester fetal anthropometric parameters are known to predict neonatal complications. A better understanding of predictors of adverse fetal parameters might help to personalize the use and frequency of fetal ultrasound. The objectives of this study were:(a) to evaluate the utility of maternal sociodemographic, anthropometric and metabolic predictors to predict 3rd trimester fetal anthropometric parameters in women with gestational diabetes mellitus (GDM),(b) to assess whether the impact of these maternal predictors is fetal sex-dependent, and(c) to provide a risk stratification for markers of fetal overgrowth (fetal weight centile (FWC) and fetal abdominal circumference centile (FACC) depending on prepregnancy BMI and gestational weight gain (GWG) until the 1st GDM visit.MethodsThis prospective study included 189 women with GDM. Maternal predictors were age, ethnicity, prepregnancy BMI, GWG and excessive weight gain until the 1st GDM visit, fasting, 1-hour and 2-hour blood glucose oral glucose tolerance test values, HbA1c at the 1st visit and medical treatment requirement. Fetal outcomes included FWC, FWC >90% and <10%, FACC, FACC >90% and <10%, at 29 0/7 to 35 6/7 weeks of gestational age. We performed univariate and multivariate regression analyses and probability analyses.ResultsIn multivariate analyses, prepregnancy BMI was associated with FWC, FWC > 90% and FACC. GWG until the 1st GDM visit was associated with FWC, FACC and FACC > 90% (all p ≤ 0.045). Other maternal parameters were not significantly associated with fetal anthropometry in multivariate analyses (all p ≥ 0.054). In female fetuses, only GWG was associated with FACC (p= 0.044). However, in male fetuses, prepregnancy BMI was associated with FWC, FWC > 90% and FACC and GWG with FWC in multivariate analyses (all p ≤ 0.030). In women with a prepregnancy BMI of ≥ 25 kg/m2 and a GWG until the 1st GDM visit ≥ 10.3 kg (mean GWG), the risk for FWC > 90% and FACC > 90% was 5.3 and 4 times higher than in their counterparts.ConclusionsA personalized fetal ultrasound surveillance guided by fetal sex, prepregnancy BMI and GWG may be beneficial in reducing adverse fetal and neonatal outcomes.

Real-World Adherence to Nodal Surveillance for Sentinel Lymph Node-Positive Melanoma.

Patients with sentinel lymph node-positive (SLN+) melanoma are increasingly undergoing active nodal surveillance over completion lymph node dissection (CLND) since the Second Multicenter Selective Lymphadenectomy Trial (MSLT-II). Adherence to nodal surveillance in real-world practice remains unknown. In a retrospective cohort of SLN+ melanoma patients who underwent nodal surveillance at a single institution from July 2017 through April 2021, this study evaluated adherence to nodal surveillance ultrasound (US). Adherence to nodal US was compared with adherence to other surveillance methods based on receipt of adjuvant therapy. Early recurrence data were reported using descriptive statistics. Among 109 SLN+ patients, 37 (34%) received US surveillance at recommended intervals. Of the 72 (66%) non-adherent patients, 16 were lost to follow-up, and 33 had planned follow-up at an outside institution without available records. More patients had a minimum of bi-annual clinic visits (83%) and cross-sectional imaging (53%) compared to those who were adherent with nodal US. The patients who received adjuvant therapy (60%) had fewer ultrasounds (p < 0.01) but more exams (p < 0.01) and a trend toward more cross-sectional imaging (p = 0.06). Of the overall cohort, 26 patients (24%) experienced recurrence at a median follow-up period of 15 months. Of these recurrences, 10 were limited to the SLN basin, and all of these isolated nodal recurrences were resectable. Pragmatic challenges to real-world delivery of nodal surveillance remain after MSLT-II, and adjuvant therapy appears to be associated with a decreased likelihood of US adherence. Understanding US utility alongside cross-sectional imaging will be critical as increasingly more patients undergo nodal surveillance and adjuvant therapy.

Long-term follow-up ultrasonography surveillance in a large cohort of patients with papillary thyroid carcinoma.

This study aimed to investigate the predictive factors as well as the time and age course of recurrence/persistence in a large cohort of postoperative patients with papillary thyroid carcinoma (PTC) based on the long-term ultrasonography (US) follow-up data. Between January 2007 and December 2016, 3106 patients underwent surgery for PTC and at least two postoperative US follow-up examination over more than three years. Tumor recurrence/persistence was confirmed based on the follow-up US data and histopathological results. Univariate and multivariate analyses were performed to evaluate the predictive factors of tumor recurrence/persistence. Kaplan-Meier survival analysis was used to evaluate the recurrence-/persistence-free survival curve based on the US results. A total of 321(10.3%) patients developed tumor recurrence/persistence during 54.3 months of mean follow-up (range 36-135 months), including 268(83.5%) cases of lymph node recurrence/persistence, 37 (11.5%) cases of non-lymph node recurrence/persistence, and 16(5%) cases of both types. Recurrence/persistence was observed using US examination at a mean interval of 23.6 ± 21.6 months (range 1-135 months) after surgery and peak incidence was observed 1-2 years after initial treatment. Younger (20-30 years old) and older (70-80 years old) patients had a higher proportion of tumor recurrence/persistence. Multifocality, advanced T and advanced N stages were independent risk factors of tumor recurrence/persistence. Tumor recurrence/persistence of PTC usually occurs during the early postoperative period. For patients with multifocal cancer, advanced T and N stage, the US surveillance examination should be cautiously performed, especially in younger and older patients.

Magnetic Nanobubble Mechanical Stress Induces the Piezo1-Ca2+ -BMP2/Smad Pathway to Modulate Neural Stem Cell Fate and MRI/Ultrasound Dual Imaging Surveillance for Ischemic Stroke.

Neural stem cells (NSCs) are used to treat various nervous system diseases because of their self-renewal ability and multidirectional differentiation potential. However, an insufficient ability to track their migration in vivo and poor control over their survival and differentiation efficiency are two major critical challenges for clinical application. Here, it is shown that when magnetic nanobubbles (MNBs), which are assembled from magnetic nanoparticles, are internalized by NSCs, intramembrane volumetric oscillation of the MNBs induces an increase in intracellular hydrostatic pressure and cytoskeleton force, resulting in the activation of the Piezo1-Ca2+ mechanosensory channel. This subsequently triggers the BMP2/Smad biochemical signaling pathway, leading to differentiation of NSCs into the neuronal phenotype. Signaling through the Piezo1-Ca2+ -BMP2/Smad pathway can be further accelerated by application of an external shear stress force using low-intensity pulsed ultrasound. More importantly, magnetic resonance imaging and ultrasound imaging surveillance of NSCs based on MNB labeling can be leveraged to provide NSC therapeutic outcomes. Both the in vitro and in vivo findings demonstrate that a bubble nanostructure-induced physical force can modulate and control the mechanical signaling pathway regulating stem cell development.

Abstract 124: Regulatory T Cells Suppress Aortic Aneurysm Growth In Mice Through Local Tissue Changes And Lymph Node Colonization

Previous studies have shown that adoptive cell transfer (ACT) of regulatory T cells (Tregs) mitigate AAA growth in mice, however these studies have used a dissection AAA model and have not thoroughly studied Treg function in mice after ACT. Treg suppression of systemic or local inflammation has not been rigorously studied in our model. We therefore sought to evaluate the effects of Treg ACT in mice with a specific focus on Treg migration, colonization, and inflammatory changes within local tissue. Methods: AAA was induced in B57Bl/6 mice expressing the Thy 1.2 allele using a topical elastase + BAPN model (E-BAPN). Heat inactivated elastase (HiE-BAPN) was used as a control. On postoperative day (POD) 2, animals were treated with PBS (E-BAPN-PBS) injection or ACT of 2 million Tregs (E-BAPN-Tregs). CD4+ CD25+ FoxP3+ Tregs used for ACT were isolated from B57Bl/6 mice expressing the Thy 1.1 allele. Mice underwent surveillance ultrasounds (US) weekly to track AAA growth for 42 days. At specific time points mice were sacrificed and aortic diameter was recorded. Aortic tissue and regional lymph nodes were harvested for analysis. Results: Maximum aortic diameter (MAD) by both US and video microscopy was significantly higher in the AAA group (E-BAPN vs. HiE-BAPN; p&lt;.001) with changes observed by POD 7. Mice treated with ACT had significantly reduced MAD (E-BAPN-Tregs vs. E-BAPN-PBS; p&lt;.05) with significant changes identified by POD 21. Thy1.1+ Tregs were detected in the tissue and regional aortic lymph nodes (LN) until day 42 with only a slight declination in the percent Thy1.1 + cells over time. Thy1.1+ Tregs retained phenotypic markers over time. E-BAPN-Treg mice had significantly altered inflammatory markers compared to E-BAPN-PBS mice including local macrophage and T-cell composition as well as inflammatory cytokines. Conclusion: Treg ACT suppress AAA growth in a topical elastase + BAPN mouse model through tissue and LN colonization and alteration of the local inflammatory milieu.

Salpingo-oophorectomy or surveillance for ovarian endometrioma in asymptomatic premenopausal women: a cost-effectiveness analysis

The lifetime risk of ovarian cancer is 1.9% among women with endometriosis compared with 1.3% among the general population. When an asymptomatic endometrioma is incidentally discovered on imaging, gynecologists must weigh the procedural complications and the potential for subsequent surgical menopause against future ovarian pathology or cancer. We aimed to determine if performing unilateral salpingo-oophorectomy is a more cost-effective strategy for the prevention of death than surveillance for asymptomatic endometriomas. We created a cost-effectiveness model using TreeAge Pro (TreeAge Software Inc; Williamstown, MA) with a lifetime horizon. Our hypothetical cohort included premenopausal patients with 2 ovaries who did not desire fertility. Those diagnosed with asymptomatic endometrioma underwent either unilateral salpingo-oophorectomy or surveillance (ultrasound 6-12 weeks after diagnosis, then annually). Our primary effectiveness outcome was mortality, including death from ovarian cancer or surgery and all-cause mortality related to surgical menopause (± hormone replacement therapy) if the contralateral ovary is removed. We modeled the probabilities of surgical complications, occult malignancy, development of contralateral adnexal pathology, surgical menopause, use of hormone replacement therapy, and development of ovarian cancer. The costs included surgical procedures, complications, ultrasound surveillance, hormone therapy, and treatment of ovarian cancer, with information gathered from Medicare reimbursement data and published literature. Cost-effectiveness was determined using the incremental cost-effectiveness ratio of Δ costs / Δ deaths with a willingness-to-pay threshold of $11.6 million as the value of a statistical life. Multiple 1-way sensitivity analyses were performed to evaluate model robustness. Our model demonstrated that unilateral salpingo-oophorectomy is associated with improved outcomes compared with surveillance, with fewer deaths (0.28% vs 1.50%) and fewer cases of ovarian cancer (0.42% vs 2.96%). However, it costs more than sonographic surveillance at $6403.43 vs $5381.39 per case of incidental endometrioma. The incremental cost-effectiveness ratio showed that unilateral salpingo-oophorectomy costs $83,773.77 per death prevented and $40,237.80 per case of ovarian cancer prevented. As both values were well below the willingness-to-pay threshold, unilateral salpingo-oophorectomy is cost-effective and is the preferred strategy. If unilateral salpingo-oophorectomy were chosen over surveillance for premenopausal patients with incidental endometriomas, 1 diagnosis of ovarian cancer would be prevented in every 40 patients and 1 death averted in every 82 patients. We performed 1-way sensitivity analyses for all input variables and determined that there were no reasonable inputs that would alter our conclusions. Unilateral salpingo-oophorectomy is cost-effective and is the preferred strategy compared with surveillance for the management of incidental endometrioma in a premenopausal patient not desiring fertility. It incurs fewer deaths and fewer cases of ovarian cancer with costs below the national willingness-to-pay thresholds.

Contribution of portable obstetric ultrasound service innovation in averting maternal and neonatal morbidities and mortalities at semi-urban health centers of Ethiopia: a retrospective facility-based study

BackgroundThe maternal and neonatal mortalities in Ethiopia are high. To achieve the Sustainable Development Goals, innovations in ultrasound scanning and surveillance activities have been implemented at health centers for over 2 years. This study aims to estimate the contribution of obstetric ultrasound services on averted maternal and neonatal morbidities and mortalities in Ethiopia.MethodsA retrospective facility-based cross-sectional study design was conducted in 25 selected health centers. Data were extracted from prenatal ultrasound registers. SPSS version 25 was used for analysis. To claim statistically significant relationship among sartorial variables, a chi-square test was analyzed and P < 0.05 was the cut-off point.ResultsOver the 2 years, 12,975 pregnant women were scanned and 52.8% of them were residing in rural areas. Abnormal ultrasound was reported in 12.7% and 98.4% of them were referred for confirmation of diagnosis and treatment. The ultrasound service has contributed to the prevention of 1,970 maternal and 19.05 neonatal morbidities and mortalities per 100,000 and 1,000 live births respectively. The averted morbidities and mortalities showed a statistically significant difference among women residing in rural and semi-urban areas, X,2 df (10) = 24.07, P = 0. 007 and X,2 df (5) = 20.87. P = 0.00, 1 respectively.ConclusionAfter availing the appropriate ultrasound machines with essential supplies and capacitating mid-level providers, significant number of high-risk pregnant women were identified on time and managed or referred to health facilities with safe delivery services. Therefore, scaling-up limited obstetric ultrasound services in similar setups will contribute to achieving the Sustainable Development Goals by 2030. It is recommended to enhance community awareness for improved utilization of ultrasound services by pregnant women before the 24th week of gestational age.

Summary of Meta-analyses of Studies Considering Lesion Size Cut-off Thresholds for The Assessment of Eligibility for FNAB and Sonoelastography and Inter- and Intra-observer Agreement in Estimating the Malignant Potential of Focal Lesions of The Thyroid Gland.

Thyroid cancer is a tumour with a steadily increasing incidence. It accounts for 7% to 15% of focal lesions detected by ultrasound, depending on age, gender and other factors affecting its occurrence. Fine-needle aspiration biopsy is an essential method to establish the diagnosis but, in view of its limitations, sonoelastography is seen as a non-invasive technique useful in differentiating the nature of lesions and monitoring them after fine-needle aspiration biopsy. This paper presents a literature review on the role of both sonoelastographic techniques (relative strain sonoelastography, shear wave sonoelastography) to assess the deformability of focal thyroid lesions. Ultrasound examination is a relatively subjective method of thyroid imaging, depending on the skills of the examiner, the experience of the centre, and the quality of equipment used. As a consequence, there are inconsistencies between the results obtained by different examiners (inter-observer variability) and by the same examiner (intra-observer variability). In this paper, the authors present a review of the literature on inter-observer and intra-observer variability in the assessment of individual features of ultrasound imaging of focal lesions in the thyroid. In addition, the authors report on an analysis of cut-off thresholds for the size of lesions constituting the basis for fine-needle aspiration biopsy eligibility assessment. The need to diagnose carcinomas up to 10 mm in diameter is highlighted, however a more liberal approach is recommended in terms of indications for biopsy in lesions associated with a low risk of malignancy, where, based on consultations with patients, active ultrasound surveillance might even be considered.

Segmental Distribution of Hepatocellular Carcinoma in Cirrhotic Livers.

Background: To evaluate the segmental distribution of hepatocellular carcinoma (HCC) according to Couinaud’s anatomical division in cirrhotic patients. Methods: Between 2020 and 2021, a total of 322 HCC nodules were diagnosed in 217 cirrhotic patients who underwent computed tomography (CT) or magnetic resonance imaging (MRI) for the evaluation of suspicious nodules (>1 cm) detected during ultrasound surveillance. For each patient, the segmental position of the HCC nodule was recorded according to Couinaud’s description. The clinical data and nodule characteristics were collected. Results: A total of 234 (72.7%) HCC nodules were situated in the right lobe whereas 79 (24.5%) were detected in the left lobe (p < 0.0001) and only 9 nodules were in the caudate lobe (2.8%). HCC was most common in segment 8 (n = 88, 27.4%) and least common in segment 1 (n = 9, 2.8%). No significant differences were found in the frequencies of segmental or lobar involvement considering patient demographic and clinical characteristics, nodule dimension, or disease appearance. Conclusions: The intrahepatic distribution of HCC differs among Couinaud’s segments, with segment 8 being the most common location and segment 1 being the least common. The segmental distribution of tumour location was similar to the normal liver volume distribution, supporting a possible correlation between HCC location and the volume of hepatic segments and/or the volumetric distribution of the portal blood flow.

Fertility Sparing Surgery and Borderline Ovarian Tumours

Simple SummaryFertility-sparing surgery (FSS) is now a widely acceptable treatment for the management of Borderline Ovarian Tumours (BOTs) in women of reproductive age. However, many clinicians face the dilemma of balancing the risks of disease recurrence with progression to lethal malignancy whilst preserving fertility, in the absence of clear standardized guidelines. The aim of this study was to evaluate the oncological outcomes in women who underwent FSS for the management of primary, or recurrent presentation of BOTs, to provide clinicians with further evidence of the safety and feasibility of FSS. Oncological outcomes following a novel method of FSS in the form of laparoscopic ultrasound guided ovarian wedge resection has also been introduced, which has the potential to change the way BOTs are managed in the future in women of reproductive age.To determine the oncological outcomes following fertility-sparing surgery (FSS) for the management of Borderline Ovarian Tumours (BOTs). A retrospective analysis of participants diagnosed with BOTs between January 2004 and December 2020 at the West London Gynaecological Oncology Centre was conducted. A total of 172 women were diagnosed; 52.3% (90/172) underwent FSS and 47.7% (82/172) non-FSS. The overall recurrence rate of disease was 16.9% (29/172), of which 79.3% (23/29) presented as the recurrence of serous or sero-mucinous BOTs and 20.7% (6/29) as low-grade serous carcinoma (LGSC). In the FSS group, the recurrence rate of BOTs was 25.6% (23/90) presenting a median 44.0 (interquartile range (IQR) 41.5) months, of which there were no episodes of recurrence presenting as LGSC reported. In the non-FSS group, all recurrences of disease presented as LGSC, with a rate of 7.7% (6/78), following a median of 47.5 months (IQR 47.8). A significant difference between the type of surgery performed (FSS v Non-FSS) and the association with recurrence of BOT was observed (Pearson Chi-Square: p = 0.000; x = 20.613). Twelve women underwent ultrasound-guided ovarian wedge resection (UGOWR) as a novel method of FSS. Recurrence of BOT was not significantly associated with the type of FSS performed (Pearson Chi- Square: x = 3.166, p = 0.379). Non-FSS is associated with negative oncological outcomes compared to FSS, as evidenced by the higher rate of recurrence of LGSC. This may be attributed to the indefinite long-term follow up with ultrasound surveillance all FSS women undergo, enabling earlier detection and treatment of recurrences.

20years review of antenatal diagnosis of haemoglobin Bart's disease and treatment with intrauterine transfusion.

To review prenatal diagnosis and outcome of alpha thalassaemia major through universal antenatal screening. This was a retrospective study on ultrasound features, antenatal diagnosis, in-utero intervention and long term outcome of pregnancies at risk of Haemoglobin Bart's hydrops foetalis syndrome attending prenatal diagnosis from 2000 to 2019 at Tsan Yuk Hospital in Hong Kong. Among 390 foetuses from 373 at-risk pregnancies, 122 (31%) prenatal invasive procedures were performed and 65 affected foetuses were diagnosed antenatally. For foetuses with ultrasound features of anaemia, the diagnostic yield of BHFS was 73%. Cardiomegaly carried a positive predictive value of 65.2% while its absence had the highest negative predictive value (96.0%). Three women having affected foetuses continued pregnancy and received intrauterine transfusion beginning 20weeks of gestation. All babies were born alive and non-hydropic. They were managed with regular transfusion and cured by haematopoietic stem cell transplantation. Absence of ultrasound features of anaemia had high negative predictive value for alpha thalassaemia major. Couple at risk of having affected foetus could be offered serial ultrasound surveillance. Invasive testing for pregnancies with features of foetal anaemia provided high diagnostic yield. Intrauterine transfusion corrected foetal anaemia and allowed long term transfusion free survival without significant neurological sequelae following postnatal transplant therapy.

Surveillance of hepatobiliary cancers in primary sclerosing cholangitis: a preliminary study on the role of PET-MRI

Introduction: Primary sclerosing cholangitis (PSC) is a rare chronic cholestatic disease with a progressive course toward cirrhosis and its complication. Moreover, these patients have an increased risk of hepatobiliary (HPB) and colorectal cancer. Current guidelines recommend performing annual ultrasound for gallbladder cancer surveillance, annual colonoscopy in patients with associated inflammatory bowel disease and 6-months ultrasound surveillance in cirrhotic patients. Despite the lack of evidence, most expert centers worldwide also perform annual MRI in combination with CA19-9 for HPB cancer surveillance.

A multivariate parametric empirical Bayes screening approach for early detection of hepatocellular carcinoma using multiple longitudinal biomarkers.

The early detection of hepatocellular carcinoma (HCC) is critical to improving outcomes since advanced HCC has limited treatment options. Current guidelines recommend HCC ultrasound surveillance every 6 months in high-risk patients however the sensitivity for detecting early stage HCC in clinical practice is poor. Blood-based biomarkers are a promising direction since they are more easily standardized and less resource intensive. Combining of multiple biomarkers is more likely to achieve the sensitivity required for a clinically useful screening algorithm and the longitudinal trajectory of biomarkers contains valuable information that should be utilized. We propose a multivariate parametric empirical Bayes (mPEB) screening approach that defines personalized thresholds for each patient at each screening visit to identify significant deviations that trigger additional testing with more sensitive imaging. The Hepatitis C Antiviral Long-term Treatment against Cirrhosis (HALT-C) trial provides a valuable source of data to study HCC screening algorithms. We study the performance of the mPEB algorithm applied to serum -fetoprotein, a widely used HCC surveillance biomarker, and des- carboxy prothrombin, an HCC risk biomarker that is FDA approved but not used in practice in the United States. Using cross-validation, we found that the mPEB algorithm demonstrated moderate but improved sensitivity compared to alternative screening approaches. Future research will validate the clinical utility of the approach in larger cohort studies with additional biomarkers.

Salpingo-oophorectomy or surveillance for ovarian endometrioma in asymptomatic premenopausal women?: a cost-effectiveness analysis

The lifetime risk of ovarian cancer is 1.9% among women with endometriosis compared to 1.3% among the general population. When an asymptomatic endometrioma is incidentally discovered on imaging, gynecologists must weigh procedural complications and surgical menopause against future ovarian pathology or cancer. We aimed to determine if performing unilateral salpingo-oophorectomy (USO) is a cost-effective strategy for prevention of death compared to surveillance for asymptomatic endometriomas. We created a cost-effectiveness model using TreeAge Pro with a lifetime time horizon. Our hypothetical cohort included premenopausal patients with two ovaries who do not desire fertility. Those diagnosed with asymptomatic endometrioma underwent USO or surveillance (ultrasound 6-12 weeks after diagnosis, then annually). Our primary effectiveness outcome was mortality, including death from ovarian cancer or surgery and all-cause mortality related to surgical menopause (+/- hormone replacement therapy). We modeled the probabilities of surgical complications, occult malignancy, development of contralateral adnexal pathology, surgical menopause, use of hormone replacement therapy, and development of ovarian cancer. Costs included surgical procedures, complications, ultrasound surveillance, hormone therapy, and treatment of ovarian cancer, with information gathered from Medicare reimbursement data and published literature. Cost-effectiveness was determined using the incremental cost-effectiveness ratio (ICER) of Δ costs / Δ deaths with a willingness to pay (WTP) of $11.6 million as the value of a statistical life. Multiple one-way sensitivity analyses were performed to evaluate model robustness. Our model demonstrated that USO costs more than surveillance ($6,403.43 vs. $5,381.39 per case of incidental endometrioma). However, USO improved outcomes with fewer deaths (0.28% vs.1.50%) and fewer cases of ovarian cancer (0.42% vs. 2.96%) than surveillance. The ICER revealed that USO costs $83,773.77 per death prevented and $40,280.46 per case of ovarian cancer prevented compared to surveillance. As both values were well below the WTP threshold, USO is cost-effective and the preferred strategy. If USO were chosen over surveillance for premenopausal patients with incidental endometriomas, one diagnosis of ovarian cancer would be prevented in every 40 patients and one death averted in every 82 patients. We performed one-way sensitivity analyses for all input variables and determined that there were no reasonable inputs that would alter our conclusions. USO is cost-effective and the preferred strategy compared to surveillance for the management of incidental endometrioma in a premenopausal patient not desiring fertility. USO incurs fewer deaths and fewer cases of ovarian cancer with costs below national willingness to pay thresholds.

Association between ultrasound quality and test performance for HCC surveillance in patients with cirrhosis: a retrospective cohort study.

Ultrasound visualisation is limited in approximately 20% of patients with cirrhosis undergoing hepatocellular carcinoma (HCC) surveillance; however, it is unknown if impaired visualisation directly impacts test performance. We aimed to evaluate the association between ultrasound visualisation and surveillance test performance. We performed a retrospective cohort study among patients with cirrhosis, with or without HCC, who underwent ultrasound-based surveillance at two large health systems between July 2016 and July 2019. Ultrasound visualisation assessment was recorded by interpreting radiologists using the ultrasound LI-RADS Visualisation score. We performed logistic regression analyses to evaluate the association between ultrasound visualisation and diagnostic test performance. We assessed sensitivity for HCC detection among ultrasounds performed in the year prior to HCC diagnoses and specificity using ultrasounds in those without HCC. Among 186 patients with HCC, severely limited visualisation (Vis Score C) on ultrasound prior to HCC diagnosis was associated with increased odds of false-negative results, that is lower sensitivity (OR 7.94, 95% CI 1.23-51.16) in multivariable analysis. Ultrasound sensitivity with visualisation scores A or B exceeded 75%, compared to only 27.3% with visualisation score C. Among 2052 cirrhosis patients without HCC, moderate visualisation limitations (Vis score B) were associated with increased odds of false-positive results (OR 1.60, 1.13-2.27), although specificity exceeded 95% across all visualisation scores. Impaired ultrasound visualisation is associated with worse surveillance test performance. Alternative blood-based biomarkers and imaging strategies are needed for patients at risk for ultrasound-based surveillance failure.

Abstract P1-01-01: Prospective ultrasonographic surveillance study for incidence and recovery period of COVID-19 vaccination-related axillary lymphadenopathy

Abstract Background: COVID-19 vaccination-related lymphadenopathy is a frequent imaging finding which may be indistinguishable from malignant nodal involvement and lead to diagnostic difficulties in patients with cancer or healthy individuals on cancer screening. An expert panel of the leading cancer centers in United States recommended routine imaging examinations should be scheduled at least 6 weeks after the final vaccination to allow for any reactive lymphadenopathy to resolve. However, there were no prospective trials regarding COVID-19 vaccination-related lymphadenopathy and the evidence was so limited. The purpose of this study was to determine the incidence and imaging characteristics of COVID-19 vaccination-related axillary lymphadenopathy and assess the recovery period. Methods: We prospectively enrolled healthy women working at the St. Luke’s International Hospital who received Pfizer COVID-19 vaccination within 8 weeks before enrollment between May 10th and 27th, 2021. Women with a history of any type of cancer or axillary surgery, active atopic dermatitis and auto-immune disease were excluded. Participants underwent ultrasound examinations for bilateral axilla at the enrollment. Lymphadenopathy was defined as demonstrating an enlarged node(s) with more than 5mm in short axis by ultrasound imaging in this trial. As for imaging characteristics, status of cortical thickening, echogenic hilus and vascularity of lymph nodes were evaluated. Other side effects by vaccination were assessed by a questionnaire. If lymphadenopathy was detected, we followed the participant by ultrasound examination every three weeks until the lymphadenopathy was resolved. We evaluated the incidence rate and imaging characteristics of lymphadenopathy detected by ultrasound examination, and the recovery period required for improvement of the lymphadenopathy. We also validated the association of the lymphadenopathy with the participant characteristics and other side effects. Results: A total of 135 women were enrolled in this study. Participants' median age was 37 years (range 23-63). Median time from the latest vaccination to the enrollment was 45 days (range 8-56). In the ultrasound examination at enrollment, axillary lymphadenopathy was observed in 67 participants (50%) on the injected (ipsilateral) side. In the contralateral axilla, 13 participants (10%) showed lymphadenopathy. In the ipsilateral axilla, the number of enlarged node(s) was 1 node in 25 cases (19%), 2 nodes in 24 cases (18%), 3 nodes in 13 cases (10%), 4 nodes in 4 cases (3%) and 5 nodes in 1 case (1%). Regarding the ipsilateral enlarged lymph node, focal cortical thickening was observed in 58 cases (43%) and the absence of the echogenic hilus was observed in 15 cases (11%). Hypervascularity was observed in 15 cases (11%). Incidence of the lymphadenopathy was not statistically correlated with participant’s age or incidence of fever due to vaccination. At 6 weeks after the latest vaccination, the rate of ipsilateral axillary lymphadenopathy was 48%, 40% at 8 weeks, and 6% at 12 weeks. In participants with lymphadenopathy, median recovery period to resolve the lymphadenopathy was 75 days from the latest vaccination. Conclusion: A half of participants showed COVID-19 vaccination-related axillary lymphadenopathy and the imaging characteristics were often indistinguishable from malignant nodal involvement. Therefore, patients with breast cancer should be vaccinated on the contralateral arm to the cancer side to avoid diagnostic conundrum. The lymphadenopathy was commonly observed even in 8 weeks, and mostly resolved after 12 weeks from the vaccination. Therefore, non-urgent imaging examinations such as screening would be recommended to be scheduled at least 12 weeks following the latest vaccination. Citation Format: Kumiko Kida, Hiroko Tsunoda, Risa Kasahara, Chika Tsutsumi, Akiko Numata, Yuri Takehara, Atsushi Yoshida, Junko Takei, Naoki Hayashi, Daiki Kobayashi, Hideko Yamauchi. Prospective ultrasonographic surveillance study for incidence and recovery period of COVID-19 vaccination-related axillary lymphadenopathy [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-01-01.

Twin Reversed Arterial Perfusion Sequence.

Twin Reversed Arterial Perfusion Sequence.

Ultrasound Surveillance of Screening Detected Subaneurysmal Aortas in 65 Year Old Men: A Five Year Rescan Predicts Those at Risk of Developing Clinically Relevant Abdominal Aortic Aneurysms

Background: The subgroup of men with an aortic diameter of 25 – 29 mm (i.e., subaneurysmal aorta [SAA]) has attracted increasing attention, not least against the background of the introduction of population screening for abdominal aortic aneurysms (AAAs). SAAs fall outside the definition of AAAs. Consequently, many screening programmes exclude individuals with SAAs from further surveillance. However, recent reports suggest that the subgroup of patients with SAA have a substantial risk of developing “true” AAAs over time and, more importantly, may reach the threshold for surgical intervention or rupture.

The Delphi definition for selective fetal growth restriction may not improve detection of pathologic growth discordance in monochorionic twins

A consensus definition of selective fetal growth restriction in monochorionic diamniotic twins was recently proposed following a Delphi procedure involving an international panel of experts. The new definition augments the traditional definition with additional sonographic criteria. We sought to determine whether the augmentations of the "Delphi definition" identified additional morbidity and mortality compared with a traditional definition. Furthermore, we sought to determine the benefit of each definition in identifying pathologic growth restriction relative to uncomplicated monochorionic diamniotic twins. This was a retrospective analysis of unselected monochorionic diamniotic twins that underwent fortnightly ultrasound surveillance at a single center between 2011 and 2020. Patients with concomitant twin-to-twin transfusion syndrome, twin anemia polycythemia sequence, or twin reversed arterial perfusion sequence at the time of diagnosis of selective fetal growth restriction were excluded. The diagnosis of selective fetal growth restriction using the Delphi definition required either an estimated fetal weight of <3rd percentile or presence of 2 of 4 observations in the smaller twin: (1) estimated fetal weight of <10th percentile, (2) estimated fetal weight discordance of >25% compared with the larger twin, (3) abdominal circumference of <10th percentile, (4) umbilical artery pulsatility index of >95th percentile. Diagnosis using the traditional definition required an estimated fetal weight of <10th percentile and an estimated fetal weight discordance of >25%. To determine the efficacy of the augmentations in the Delphi definition, 3 groups were compared: group I, uncomplicated monochorionic diamniotic twins; group II, twins with selective fetal growth restriction using the traditional definition (and therefore the Delphi definition); and group III, twins with selective fetal growth restriction solely using the Delphi definition. Demographic characteristics, subsequent development of twin-to-twin transfusion syndrome or twin anemia polycythemia sequence, pregnancy outcomes, and neonatal outcomes were compared. There were 325 patients with monochorionic diamniotic twins that met inclusion criteria. Of these, 213 (66%; group I) were uncomplicated, 37 (11%; group II) met the traditional definition for selective fetal growth restriction, and 112 (35%) met the Delphi definition for selective fetal growth restriction with 75 (67%) meeting solely the Delphi definition (group III). Demographic characteristics were similar between groups. Patients in group II delivered earlier than uncomplicated twins (32.1 vs 35.7 weeks of gestation; P<.01) and patients in group III (32.1 vs 35.6 weeks of gestation; P<.01). Furthermore, they were more likely to have critical umbilical artery Doppler abnormalities (38% vs 4%; P<.01) and be delivered for deteriorating fetal status (30% vs 5%; P<.01) than those in group III. Overall, survival was lower in group II than groups I and III (89% vs 96% and 100%, respectively; P=.04). Moreover, composite neonatal morbidity and mortality were greater in group II (30%) than either group I (6%; P<.01) or group III (9%; P<.01). The rates of composite neonatal morbidity and mortality were similar between groups I and III (P=.28). The addition of abdominal circumference and umbilical artery pulsatility index thresholds and isolated estimated fetal weight of <3%, as proposed by the Delphi definition, increased the diagnosis of selective fetal growth restriction; however, there was no added benefit in the identification of growth discordant pregnancies at risk of adverse outcomes. Prospective analysis of monochorionic diamniotic twins is required to contextualize these findings.

18F]FDG-PET/CT to prevent futile surgery in indeterminate thyroid nodules: a blinded, randomised controlled multicentre trial

PurposeTo assess the impact of an [18F]FDG-PET/CT-driven diagnostic workup to rule out malignancy, avoid futile diagnostic surgeries, and improve patient outcomes in thyroid nodules with indeterminate cytology.MethodsIn this double-blinded, randomised controlled multicentre trial, 132 adult euthyroid patients with scheduled diagnostic surgery for a Bethesda III or IV thyroid nodule underwent [18F]FDG-PET/CT and were randomised to an [18F]FDG-PET/CT-driven or diagnostic surgery group. In the [18F]FDG-PET/CT-driven group, management was based on the [18F]FDG-PET/CT result: when the index nodule was visually [18F]FDG-positive, diagnostic surgery was advised; when [18F]FDG-negative, active surveillance was recommended. The nodule was presumed benign when it remained unchanged on ultrasound surveillance. In the diagnostic surgery group, all patients were advised to proceed to the scheduled surgery, according to current guidelines. The primary outcome was the fraction of unbeneficial patient management in one year, i.e., diagnostic surgery for benign nodules and active surveillance for malignant/borderline nodules. Intention-to-treat analysis was performed. Subgroup analyses were performed for non-Hürthle cell and Hürthle cell nodules.ResultsPatient management was unbeneficial in 42% (38/91 [95% confidence interval [CI], 32–53%]) of patients in the [18F]FDG-PET/CT-driven group, as compared to 83% (34/41 [95% CI, 68–93%]) in the diagnostic surgery group (p < 0.001). [18F]FDG-PET/CT-driven management avoided 40% (25/63 [95% CI, 28–53%]) diagnostic surgeries for benign nodules: 48% (23/48 [95% CI, 33–63%]) in non-Hürthle cell and 13% (2/15 [95% CI, 2–40%]) in Hürthle cell nodules (p = 0.02). No malignant or borderline tumours were observed in patients under surveillance. Sensitivity, specificity, negative and positive predictive value, and benign call rate (95% CI) of [18F]FDG-PET/CT were 94.1% (80.3–99.3%), 39.8% (30.0–50.2%), 95.1% (83.5–99.4%), 35.2% (25.4–45.9%), and 31.1% (23.3–39.7%), respectively.ConclusionAn [18F]FDG-PET/CT-driven diagnostic workup of indeterminate thyroid nodules leads to practice changing management, accurately and oncologically safely reducing futile surgeries by 40%. For optimal therapeutic yield, application should be limited to non-Hürthle cell nodules.Trial registration numberThis trial is registered with ClinicalTrials.gov: NCT02208544 (5 August 2014), https://clinicaltrials.gov/ct2/show/NCT02208544.