Conflicting or complementary role of computed tomography (CT) and positron emission tomography (PET)/CT in the assessment of thymic cancer and thymoma: Our experience and literature review

Background: To evaluate the role of computed tomography (CT) and positron emission tomography (PET)/CT in patients with thymic cancer and thymoma at initial staging. Methods: We retrospectively reviewed CT and PET/CT scans of 26 patients with a thymic cancer (n = 9) or thymoma (n = 17). Chest CT findings documented were qualitative and quantitative. Both qualitative and semiquantitative data were recovered by PET/CT. The comparisons among histological entities, outcome, and qualitative data from CT and PET/CT were made by non-parametric analysis. Results: PET/CT resulted positive in 15/17 patients with thymoma. CT was available in 5/9 (56%) patients with thymic cancer and in 3/17 with thymoma. All quantitative CT parameters were significantly higher in patients with thymic cancer than thymoma (maximum axial diameter: 45 vs. 20 mm, maximum longitudinal diameter: 69 vs. 21 mm and volume: 77.91 vs. 4.52 mL; all P < 0.05). Conversely, only metabolic tumor volume (MTV) and total lesion glycolysis were significantly different in patients with thymic cancer than thymoma (126.53 vs. 6.03 cm3 and 246.05 vs. 20.32, respectively; both P < 0.05). After a median follow-up time of 17.45 months, four recurrences of disease occurred: three in patients with thymic cancer and one with a type B2 thymoma. CT volume in patients with recurrent disease was 102.19 mL versus a median value of 62.5 mL in six disease-free patients. MTV was higher in the recurrent than disease-free patient subset (143.3 vs. 81.13 cm3), although not statistically significant (P = 0.075). Conclusion: Our preliminary results demonstrated that both morphological and metabolic volume could be useful from a diagnostic and prognostic point of view in thymic cancer and thymoma patients. A large multi-center clinical trial experience for confirming the findings of this study seems mandatory

Synovial effusion and synovial fluid biomarkers in psoriatic arthritis to assess intraarticular tumor necrosis factor-α blockade in the knee joint

Introduction: Evaluation of synovial effusion (SE), synovial fluid (SF) and synovial tissue (ST) biomarkers in relation to disease activity indexes to assess the response to intraarticular (IA) tumor necrosis factor (TNF)-\u3b1 blockers in psoriatic arthritis (PsA). Methods: Systemic and local disease activity indexes (disease activity score [DAS]; the Ritchie articular index [mRAI], erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP); Thompson articular [THOMP] and joint articular [KJAI]-Index ) and ST samples were assessed at baseline, throughout treatment, and during the follow-up in 14 patients affected with PsA who underwent IA injections (0.5 ml - 12.5 mg) in the knee joint of etanercept (E) or placebo (P) once every two weeks for a ten week period. Total SF white blood cell (WBC) counts (WBC/ \u3bcl) and SF cytokine/chemokine (CK/CCK) levels were measured before IA-E at baseline, after IA-E, and as long as there were adequate amounts of SF for knee aspiration (post). Characterization of synovial mononuclear cell infiltration and synovial vessels was carried out in 8/14 knees by staining serial sections of synovial tissue biopsies for CD45, CD3, CD68, CD31 and CD105. Results: At baseline, CRP and/or ESR were significantly correlated with SF-CK (IL-1\u3b2, IL-1Ra, IL-6, IL-8) and CCK (CCL2, CCL3 and CCL4). Post-IA injections, there was a decrease in SE in the knees in which aspiration following IA-E injection was possible as well as a significant reduction in SF WBC/\u3bcl and in SF-CK (TNF-\u3b1, IL- 1\u3b2, IL-1Ra, IL-6 and IL-22). Pre- and post- IAE injections, there were significant correlations between ST markers and SF-CK (IL-1\u3b2 with CD45; IL-1\u3b2 and IL-6 with CD31) and between SF-CCK (CCL4 and CCL3 with CD3). At the end of the study, there was a significant reduction in disease activity indexes (CRP, DAS, RAI, THOMP, KJAI) as well as in the ST markers (CD45; CD3)

Ground glass pulmonary nodules: their significance in oncology patients and the role of computer tomography and 18F–fluorodeoxyglucose positron emission tomography

Abstract Objective to determine the clinical significance of ground glass pulmonary nodules, either pure (GGNs) or mixed with the presence of solid component (MPNs), in patients with known pulmonary or extra-thoracic malignancies and to evaluate the role of computed tomography (CT) and positron emission tomography (PET)/CT in their diagnosis and follow-up. Methods A total of 130 nodules in 68 patients were revealed: 119 GGNs and 11 MPNs. GGN lesions were found in 58 patients, MPNs in eight, and in two cases, both. The median diameter of the nodules was 7 mm (3–30 mm). Moreover, 27 patients, who had a pars-solid >5 mm in the GGN or a pure GGN with a diameter > 5 mm, underwent FDG PET/CT. The median follow-up with CT was >3 years. Results The comparison between the first and the last positive CT scan showed that GGNs and/or MPNs remained unchanged for a median period of 18 months (range 11–48 months) in 53 patients, they disappeared after a median of 3.5 months (range 2–11 months) in 12 and increased in diameter after a median period of 17 months (range 12–67 months) in 3. In particular of these latter patients, two had malignant lesions. Only three patients with a single nodule showed a significant uptake of FDG at PET/CT. Conclusion in the evaluation of GGNs and MNPs, CT examinations performed after 3 months often showed some changes, mainly with respect to nodules disappearing. PET/CT often plays no role but it can exclude malignancy at the end of staging. Finally, in patients with known pulmonary or extra-thoracic malignancies showing GGNs or MPNs, a 3-year CT follow up is justified, due to the slow growth rate of these lesions

The role of contrast-enhanced gray-scale ultrasonography in the differential diagnosis of superficial lymph nodes.

Lymph node micrometastases are common, but too often in clinical practice lack the tools for their accurate prebiopsy detection. The gray-scale contrast-enhanced ultrasonography technique permits high-resolution imaging of both the arterial and parenchymal phase and allows visualization of diffuse and partial alterations of nodal perfusion even in lymph nodes with a maximum diameter smaller than 1 cm. The gray-scale contrast-enhanced ultrasonography can supply further useful information in case where doubt has arisen with conventional techniques. The results obtained show that it affords highly accurate differentiation between benign and metastatic lymph nodes

Toward Early Detection and Differentiation of Arthritic diseases: Quantification of Haemodynamics Changes in Small Joints

Inflammatory rheumatic diseases, such as rheumatoid arthritis (RA), are leading causes of disability and constitute a frequent medical disorder, leading to inability to work, high co-morbidity and increased mortality; RA involves indirect expenses secondary to disability, loss of productivity and early retirement. The gold-standard for diagnosing RA is based on patient conditions and radiographic findings, as joint erosions or decalcification. Recently, it has been shown that development of microvessels in the synovia is the earliest sign of RA, so that identification of prognostic factors such as persistent synovial hyperaemia is fundamental. By using immersion contrast-enhanced ultrasound with a steady probe to analyse the perfusion of those joints that are the most important for early detection of RA, we propose a quantitative analysis of the contrast kinetics in the synovial and peri-synovial tissues. This analysis allows the identification and differentiation of rheumatoid arthritis from other diseases that involve synovial activity such as psoriatic arthritis. We show the results of the proposed immersion-CEUS with a semi-automatic quantification procedure of the contrast kinetics in the synovia on a set of 16 metacarpophalangeal (MCP) joints of consecutive patients affected either by RA or psoriatic arthritis. Estimated kinetics parameters allows an accurate separation of the two classes of patients, that can be further improved by using serologic data

Contrast-Enhanced Ultrasound for Characterizing Lymph Nodes With Focal Cortical Thickening in Patients With Cutaneous Melanoma

OBJECTIVE: The aim of this study was to ascertain the utility of contrast-enhanced ultrasound in assessing the significance of focal cortical thickening in the lymph nodes of patients followed up after surgery for cutaneous melanoma. MATERIALS AND METHODS: Ultrasound was used to examine 460 consecutive patients to identify nodes with focal hypoechoic cortical thickening. Patients whose nodes revealed these features underwent contrast-enhanced ultrasound and ultrasound-guided fine-needle aspiration cytology (FNAC) focusing on the area of cortical thickening. Enhancement in the arterial and parenchymal phases was evaluated: A generalized homogeneous or intense enhancement was considered benign and the presence of a perfusion defect was considered metastatic. RESULTS: After exclusion of 24 patients with frank signs of malignancy at gray-scale ultrasound, the study included 436 patients. Focal hypoechoic cortical thickening was seen in 44 of 436 nodes in as many patients. In 29 nodes, the area of focal thickening showed contrast enhancement similar to that of the remaining cortex on contrast-enhanced ultrasound. In 15 nodes, the area of cortical thickening was less well vascularized than the adjacent parenchyma in the arterial phase and there were areas with perfusion defects that were more evident in the parenchymal phase. FNAC focusing on the areas of focal cortical thickening identified 13 metastatic nodes and 31 nodes with benign features. Contrast-enhanced ultrasound compared with FNAC correctly classified 42 of 44 nodes, showing a sensitivity of 100% and a specificity of 99.5%. CONCLUSION: Although our findings need to be confirmed in larger series, they indicate that contrast-enhanced ultrasound can be useful in clinical practice for characterizing focal cortical thickening in lymph nodes. The exclusion or identification of regional lymph node metastases is of fundamental importance in oncologic staging because this issue directly influences both the prognosis and the choice of therapeutic strategy

Quality control of ultrasound transducers: analysis of evaluation parameters and results of a survey of 116 transducers in a single hospital.

PURPOSE: The aim of this study was to develop a quality control programme for ultrasound equipment and assess equipment performance at a single hospital. MATERIALS AND METHODS: We tested 116 transducers by means of a phantom; ultrasound quality control tests were done on parameters from B-mode images, and each parameter was rated according to a three-point score as good, sufficient or poor. RESULTS: Surface transducers showed worse performance in terms of image uniformity, with 7/55 (13%) transducers rated poor, and depth of penetration, with 24/55 (44%) transducers, rated sufficient or poor. The 3.5-MHz transducers showed worse performance in lateral resolution, with 18/48 (38%) rated poor, and particularly in focusing, with 40/48 (83%) classified as poor. In addition, the 3.5-MHz transducers proved less accurate in vertical distance accuracy than in horizontal distance, with 31/48 (64%) considered sufficient. No significant geometric distortions of masses were identified, although 4/116 (3%) transducers failed to visualise two masses. CONCLUSIONS: The first goal of an ultrasound quality control programme is to establish specific parameters to evaluate equipment performance and, should results be below recommended action levels, implement corrective measures

The role of sonoelastography in the differential diagnosis of neck nolules

Sonoelastography is an imaging technique that provides information on tissue elasticity. Its use as a diagnostic procedure is based on the premise that pathological processes like cancer alter the physical characteristics of the involved tissue. Ultrasonographic studies of the neck can reveal the nonpalpable thyroid nodules, but the nature of these lesions generally has to be established on the basis of FNAB findings. In our hands, sonoelastography displayed a diagnostic accuracy of 86.2% in identifying thyroid nodule malignancy, with positive and negative predictive values (PPV and NPV) of 64% and 94.5%, respectively. In the study of cervical lymph nodes, the results were less impressive (sensitivity 75%, specificity 80%, accuracy 77%, PPV 80%, NPV 70%), but the information obtained with this technique can in our opinion be a useful adjunct to sonographic findings. Indeed, in 5 lymph nodes with sonographic features consistent with malignancy, sonoelastography revealed diffuse elasticity that was indicative of benign disease, which was confirmed by pathological studies. Other nodular lesions of the neck can also be evaluated with sonoelastography, including enlarged parotid glands, but the data in the literature are too limited to allow hypotheses on the role of this imaging modality in this field. Sonoelastography is rapid and simple to perform, and it appears to be a potentially useful tool for the differential diagnosis of neck nodules. This is particularly true of thyroid nodules. Our experience with these lesions indicates that diffuse elasticity is strongly correlated with benign disease. If this finding is confirmed in larger studies, sonoelastography might be used to identify thyroid nodules that do not require immediate biopsy

Identification of distinct vascularization pattern in finger joint synovits in rheumatoid arthritis versus other forms of arthritis by contrast enhanced sonography: a preliminary study.

Background: Rheumatoid arthritis (RA) has among all forms of arthritides the worst outcome. Synovitis in RA is consistent with inflammation, synovial hyperplasia and neovascularization, that correlates with disease activity, aggressiveness and joint destruction. Contrast enhanced ultrasonography (CEUS) has been proven to be a very sensitive method in assessing synovitis in RA, equipollent to magnetic resonance imaging.1,2 The vascularization detected by CEUS in RA synovitis has not yet been compared to other forms of arthritis. Objectives: To investigate by CEUS the pattern of synovial vascularization in RA and other arthritides and to find parameters able to discriminate between both. Methods: 40 outclinic patients with arthritis of finger joints were recruited. 23 patients were affected from RA according to ACR criteria. 6 patients had severe, 11 moderate and 2 low disease activity using Das28 score. Of the 17 non RA patients 11 suffered from psoriatic arthritis, 1 from spondiloarthritis, 1 from osteoarthritis, 2 from connectivitis, 1 from septic arthritis, and 1 from arthritis in celiac disease. 5 patients presented severe, 11 moderate and 1 low disease activity. The most active joint was chosen for CEUS investigation. The hands were water-immersed and steady probe was used to increase resolution of superficial interfaces and to avoid artefacts by movement and inhomogenous gel application. Endovenous bolus injection of Sonovue was performed. For image acquisition contrast tune imaging with low mechanical index was used. Software able to recognise different articular structures and to assess pixel properties of contrast enhancement was devised by our bioengineers. Results: The most active joint of the hands in 23 RA (21 MCF and 2 IFP) and 17 patients affected by other forms of arthritis (12 MCF and 5 IFP) was analysed after contrast administration. The software identified various contrast flow parameters. 8 parameters resulted helpful in discriminating the RA from the non RA group: synovial wash-in and wash-out velocity, synovial peak intensity, fraction of synovial, capsular and peripheral-entheseal pixels, fraction of synovial and peripheral high intensity pixels. The importance for diagnosis of the single parameters was calculated by linear discriminator analysis and summed to an vascularization pattern identifying RA patients. By using this pattern 22 out of 23 RA patients resulted true positive and 1 as false negative compared to clinical diagnosis, whereas true negative results were seen in 16 out of 17 non RA patients and 1 false positive in a patient showing the rheumatoid variant of psoriatic arthritis. The sensibility and specificity was 91% and 94%. The positive predictive value was 95% and the negative predictive value 88%. Conclusion: We found by CEUS a pattern of vascularization in synovitis of rheumatoid arthritis different from that found in other forms of arthritis. In patients with arthritis CEUS represents available application to detect rheumatoid arthritis with worse prognosis and to lead therapeutic decision

Conflicting or complementary role of computed tomography (CT) and positron emission tomography (PET)/CT in the assessment of thymic cancer and thymoma

Purpose: To evaluate the role of CT and PET/CT in thymic cancer and thymoma patients at initial staging. Methods and Materials: We retrospectively reviewed CT and PET/CT of 26 patients with a proven-diagnosis of thymic cancer (n=9)and thymoma (n=17).Chest CT findings documented were qualitative (calcification, peritumoral fat infiltration,pleural-pericardial effusion, degree of abutment of vessel circumference, et al)and quantitative (maximum axial and longitudinal diameter and volume).Both qualitative and semiquantitative data (standardised uptake value, total lesion glicolysis-TLG, metabolic tumor volume-MTV)were recovered by PET/CT.The outcome of all patients was retrieved by clinical chart or observational follow-up.The comparisons among histological entities, outcome and CT and PET/CT findings were evaluated using a non-parametric analysis. Results: PET/CT resulted positive in 15 patients with thymoma.100%of patients with thymic cancer had a positive scan.CT was available in 5/9 patients with thymic cancer and in 3/17 subjects with thymoma.All quantitative CT parameters were significantly higher in patients with thymic cancer than thymoma (MAD:45vs.20 mm,MLD:69vs.21 mm and volume:77.91vs.4.52 ml;all p < 0.05).Conversely, only MTV and TLG were significantly different in patients with thymic cancer than the counterpart (126.53vs.6.03 cm3 and 246.05vs.20.32,respectively;both p < 0.05).After a median follow-up of 17.45 months, four recurrences of disease occurred (three in patients with thymic cancer and one with a type B2 thymoma).Follow-up data were lost in three subjects.CT volume in a patient with recurrent disease was 170.12 ml vs. a median value of 10.5 ml in seven disease-free patients.MTV was higher in recurrent than disease-free subset (143.3vs.81.13 cm3),although not statistically significant (p=0.075). Conclusion: Both morphological and metabolic volume can be useful for diagnostic and prognostic meaning in thymic cancer and thymoma patients