Tổng số lượt xem trang

Thứ Hai, 22 tháng 2, 2016

SHEAR WAVE ELASTOGRAPHY from APLIO 500 TOSHIBA on LIVER FIBROSIS

DOWNLOAD FULLTEXT
http://www.toshiba-medical.eu/eu/wp-content/uploads/sites/2/2014/09/WP_MOIUS0074EA_Iijima_2014-09.pdf







Thứ Sáu, 12 tháng 2, 2016

Patient's Platelet Count can Increase the Risk for Hematoma in Liver Biopsy

Image-guided liver biopsy is safe, but not risk-free
By Erik L. Ridley, AuntMinnie staff writer
February 11, 2016 -- While major adverse events from liver biopsy guided by ultrasound or CT are extremely rare, variables such as the patient's platelet count can increase the risk for hematoma from the procedure by as much as fourfold, according to a large retrospective analysis performed at the Mayo Clinic in Rochester, MN.


Thứ Ba, 9 tháng 2, 2016

Thứ Sáu, 5 tháng 2, 2016

CHÚC TẾT 2016





CHÚC MỪNG NĂM MỚI BÍNH THÂN 2016 AN KHANG THỊNH VƯỢNG.

MEDIC ARFI in BREAST TUMORS

CLINICAL FINDINGS of ARFI in BREAST TUMORS

VO NGUYEN THUC QUYEN, PHAN THANH HAI, MEDIC MEDICAL CENTER,
HCMC, VIETNAM
INTRODUCTION:
Breast Cancer is currently the top cancer among women worldwide including Viet nam. Therefore, early detection plays a critical role in clinical decision of management.
Besides Mammography and MRI, ultrasound has been a useful modality in detecting breast tumors. Moreover, the combination with Color Doppler significantly reinforces the B-mode diagnosis. Lately, new ultrasound technique, elastography is providing more information to increase accuracy. However, each one uses different method including compressed and non-compressed technologies. Developing by Siemen, ARFI is a non-compressed elastography, evaluates tissue stiffness base on replacement caused by acoustic radiation force impulse (ARFI). In other words, tissue deformed and reformed  under a force. The stifferness replaces less compared with surrounding tissue in same depth. In clinical application, tumors usually harder than healthy tissue.
AIMS:
To evaluate ARFI qualitative and quantitative assessment to differentiate benign and malignant breast tumors.
METHODS and MATERIALS
Patient and Pathologic diagnosis:
From April to November 2015, we selected 85 breast lesions classified as category 3-5 according to ACR Breast Imaging Recording and Data System (BI-RADS). Two radiologists analyzed them in the following steps before performed biopsy with final diagnosis (FNAC, Core Biopsy, Excisional Biopsy). All images and biopsy procedures were performed at Medic Medical Center Ho Chi Minh city. Exclusion criteria include:
·         Non histopathology confirmation
·         Male breast lesions
Imaging methods:
Using linear probe 9L4 (9MHz) in Siemens Acuson S2000, we applied respectively 2 modes:
·         VTI (Virtual Touch Quantification): an gray-scale elasticity map within region of interest (ROI)
·         VTQ: (Virtual Touch Quantification): quantitatively measure shear-wave speed (m/s) within non-resizable ROI. The ROI was set in multiple point of the lesion to get the mean measurement.
Step 1: scan B-mode and Color Doppler images, classified lesion using BI-RADS lexicon (shape, orientation, border, echotexture, posterior feature)
 Step 2: Acquired Elasticity Score (E.S) in VTI mode then measure Area Ratio (proportion between VTI lesion area and B-mode area). Base on VTI map, we classified lesions with 5 elasticity score: Figure
            Score 1: totally white
            Score 2: mosaic (mix multi-shade of grey and white)
            Score 3: black core with white or grey or mix
            Score 4: totally or near to complete black
            Score 5: totally black with black component out of lesion
Score1-3: low suspect of malignancy
Score 4-5: high suspect of malignancy

Step 3: Set ROI in 5 different points of the lesion then measured Shear-wave Velocity (SWV) in VTQ mode. We calculated mean velocity for each lesion. The ROI in VTQ mode are fixed with 5 x 5 mm in size. When acquired velocity reach over 9.10m/s or computer is unable to get the signal, we have X.XX m/s as value. [1] Figure 2.







Figure 2: Shearwave travels through hard tissue very fast with > 9.10m/s (X.XX m/s value)
Statistic analysis:
We use SPSS version 16.0 to identified cut-off value and obtain ROC for best value of sensitivity and specificity. Once we get cut-off value, we use t-student analysis to see whether benign and malignant populations were statistically different.
           
RESULT
This study was approved by the institutional review board and informed consent was obtained from all participants. From April to November 2015, we selected 85 breast lesions including 59 benign (69.4%) and 26 (30.6%) malignant. Lesions appear to dominantly locate in right breast 52/85 (61.2%), left 33/85 (38.8%). The mean size 16.26 ±6.56 width and  9.64 ±5.01 mm depth
Histopathologic diagnosis
n (%)
Malignant:  Invasive ductal carcinoma
26 (29.4)




Benign
59 (70.6)
Fibroadenoma
5 (5.9)
Mastitis
3 (3.5)
Intraductal papilloma
2 (2.4)
Fibrocystic change
46 (55.3)
Others
3 (3.5)
Total
85 (100)
Table 1: histopathlogic diagnosis of malignant and benign breast lesions
ARFI analysis
-VTI:
a/ Elasticity Score (E.S)

Malignant (%)
Benign (%)
ES 1
0
0
ES 2
0
52.5
ES 3
0
47.5
ES 4
23.1
0
ES 5
76.9
0
Total
100
100
Table 2.1: ES Score frequency of malignant and benign lesion
As the table 2.1, 26/26 cancer cases has ES 4-5 within suspicious range.
b/ Area ratio (A.R)
Area Ratio
Sensitivity (%)
Specificity (%)
1.06
100
27.2
1.13
96.2
52.5
1.20
88.5
64.4
1.34
88.5
94.9
1.40
84.6
96.6
1.44
84.6
98.3
Table 2.2:

As the table 2.2, the AR cut-off point would best at 1.34 with sensitivity 88.5% and specificity 94.9%. Area under ROC curve for malignancy is 0.933.
-VTQ:
We excluded 8 malignant cases has SWV as X.XX m/s
SWV
Sensitivity (%)
Specificity (%)
2.20
100
69.5
2.24
94.4
72.9
2.32
88.9
79.7
2.41
83.3
83.1
2.49
77.8
88.1
Table 2.3:
As the table 2.3, the SWV cut-off point would best at 2.24 with sensitivity 94.4% and specificity 72.9%. Area under ROC curve for malignancy is 0.911.
DISCUSSION
The ability of early detection
ARFI helps in differentiate malignant and benign lesion. E.S score in VTI mode suggest suspicion are quite accurate in this study (26/26). The gray-scale map not only distinguish big tumors but also in small tumors as case demonstrated (Figure 3). It could greatly aid in early detection.
Figure 3: A DCIS 6 x 5 mm mass with BI-RADS 5 in B-mode and ES 5, infiltration is clearly demonstrated which is not visible on conventional B-mode.
In term of quantitative evaluation, Area Ratio reinforced E.S. It also shows a better the cancerous infiltration in surrounding tissue than conventional method. In conventional ultrasound, only when halo rings, architecture distortion, skin changes suggest infiltration. However, those present in late stage while we are aiming for early detection. (Figure 4)
Firgure 4: non-halo tumors with AR=1.81 is better demonstrated the surrounding invasion
Our cut-off value
Our SWV cut-off point at 2.24 m/are suitable for clinical practice. Other reference studies were significantly higher (Yoon Seok Kim et al: 4.23±1.09 m/sec [2]) as they considered all X.XX value as 9.10m/s. We excluded all X.XX value since it not actually equals 9.10m/s.
Role in clinical diagnosis
In clinical application, ARFI increases the accuracy of B-mode and Color Doppler. It most value in BI-RADS 3-4a lesion which are the borderline between benignity and malignancy. We recommended grade up from BI-RADS 3 to 4A if all ARFI features are suspicious. However, here are some exceptions. Acknowledged that some cancer such as Inflammatory Breast Cancer (IBC) tends to be softer than normal tissue, reversely, some benign condition like Mastitis can mask malignancy (figure 5). Our study limited in 85 case and not included any IBC however caution should be made if specially AR> 1.34. An interesting study was held by M.Teke et al. which used ARFI to compare Idiopathic Granulomatous Mastitis with Breast Cancer . Study shown significantly different between their SWV (cut-off value 4.08m/s with 80.6% sensitivity, 86.4% specificity). It is important not to miss cancer but still minimalize invasive option. EFSUMB also recommend this concept but less certain in down grade. In some situation, we can down grade 4A lesion if the technique done right, such as circumscribed lesion with suspicious Doppler pattern or posterior feature. ARFI also helps guiding FNA procedure as we puncture the hardest points in the lesion on VTI map.  

Figure 5: Mastitis lesion in 60 years old patient, BI-RADS 4C E.S 2, AR=1.1 and VTQ=1.58m/s


Technical recommendation


CONCLUSION
Overall, ARFI is a useful tools for diagnosis and biopsy guidance breast tumors. The technique is simple since it is non-compressed and repeatable. It cannot replaced biopsy but reinforced conventional ultrasound. This is a promising technique helps avoiding invasive diagnosis if we use it right and well-combined with other features.

REFERENCES:
1/ Wojcinski S, Brandhorst K, Sadigh G, Hillemanns P, Degenhardt F. Acoustic radiation force impulse imaging with Virtual TouchTM tissue quantification: mean shear wave velocity of malignant and benign breast masses. International Journal of Women’s Health. 2013;5:619-627. doi:10.2147/IJWH.S50953.
2/ Kim YS, Park JG, Kim BS, Lee CH, Ryu DW. Diagnostic Value of Elastography Using Acoustic Radiation Force Impulse Imaging and Strain Ratio for Breast Tumors. Journal of Breast Cancer. 2014;17(1):76-82. doi:10.4048/jbc.2014.17.1.76.
3/ M. Teke, M. Gümüş, F. Teke. Combination of elastography and tissue quantification using the acoustic radiation force impulse technology for differential diagnosis of Idiopathic Granulomatous Mastitis with Breast Cancer. ECR 2015 http://dx.doi.org/10.1594/ecr2015/C-1835

4/D. Cosgrove1, F. Piscaglia2, J. Bamber3. EFSUMB Guidelines and Recommendations on the Clinical Use of Ultrasound Elastography.Part 2: Clinical Applications. Ultraschall in Med 2013 DOI: 10.1055/s-0033-1335375

Thứ Hai, 1 tháng 2, 2016

ULTRASOUND ANATOMY INCREASES UNDERSTANDING of LIVING ANATOMY





Abstract

Despite increase in residency programs including ultrasound training, few medical schools have incorporated it into their curricula. The Gross Anatomy course at Mayo Medical School has introduced ultrasound in the curriculum. Cadaver dissection teaches students static anatomical relationships, but ultrasound offers dynamic display of how those relationships can change with movement. Ultrasound curriculum consists of four 1 hour didactic sessions and five 30 minute hands-on modules, covering Carpal tunnel, Heart, Abdominal viscera, and Doppler imaging of blood flow. Each module is guided by a checklist of techniques and structures. Students are graded using ARS system, and ultrasound objectives are incorporated into the final exam. This study aimed to assess effectiveness of ultrasound curriculum in a 7 week anatomy course. Students were asked to complete pre- and post- test surveys that assessed whether ultrasound sessions allowed them to better appreciate living anatomy, learn the basics of operating a portable ultrasound machine, and become more comfortable with medical technology. Pre and post surveys showed that ultrasound helped students appreciate living anatomy, and that they were comfortable with technology. There was an increase in students’ perception of their ability to interpret ultrasound images with a p-value of 0.000026. Ultrasound was a successful addition to the anatomy curriculum.

MEDIC CHUẨN BỊ THAM DỰ AFSUMB 2016

1/ ARFI of TESTIS at MEDIC CENTER, NGUYEN THIEN HUNG - LE VAN TAI - PHAN THANH HAI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

PURPOSE:
Acoustic radiation force impulse imaging (ARFI) is a new technique for the sonographic quantification of tissue elasticity. We applied  ARFI elastography to investigate the stiffness of  the normal and pathologic testes.

METHOD and MATERIALS:
20 male volunteers underwent normal B-mode sonography with ARFI elastometry of both testes using a Siemens Acuson S2000™ (Siemens Healthcare, Germany) system. 12 cases of testicular tumor  and 03 cases of hematoma were encountered in our study.  Results were statistically evaluated.
RESULTS:
-          From 40 normal testes of 20 male individuals, mean elastic velocity VTQ= 0.87+/- 0.11m/s [range 0.72-1.12 m/s]
-          From 03 cases of hematoma, mean elastic velocity VTQ=1.39+/-0.02m/s.
-          From 12 cases of testicular tumor, mean elastic velocity VTQ= 1.51+/- 0.18 m/s (range 1.26-1.69m/s) with the meaning more stiffness than normal and hematoma testis. On VTI tumor are harder the parenchyma (black color or blue code)

CONCLUSION:
ARFI elastometry  provides the initial values of testicular stiffness in normal and pathologic status. Further studies with more subjects may be required to define the normal range of values for normal and pathologic groups.

2/ARFI for OBSTRUCTIVE and with UPJO HYDRONEPHROSIS in ALDULT
NGUYEN THIEN HUNG - TRAN NGAN CHAU- PHAN THANH HAI, MEDIC MEDICAL CENTER, HCMC, VIETNAM
ABSTRACT:
We applied ARFI technique from Siemens S2000 to evaluate whether fibrotic process existing in adult hydronephrosis.
Using 1-4 MHz convex probe we calculated in 3 positions of hydronephotic kidney due to  obstruction [stone, outside compression] (n=33 cases), due to ureteropelvic junction obstruction [UPJO] (n=30 cases]. We had a control group of normal kidney (n=36 cases). Mean value of ARFI velocity of obstruction hydronephrosis (due to stone) was 2.73+/-0.39m/s and of UPJO hydronephrosis was 1.66+/-0.16m/s while in control group was 1.6+/-0.2m/s. There were stastistic differences of 2 stone and UPJO hydronephrosis groups (p < 0.0001), with stone hydronephrosis and control (p < 0.0001). But no statistic difference exists in UPJO hydronephrosis and control group.

3/ CLINICAL APPLICATION of Acoustic Radiation Force  Impulse  in BREAST TUMOR at MEDIC CENTER, PHAN THANH HAI PHUONG, VO NGUYEN THUC QUYEN, PHAN THANH HAI

INTRODUCTION
Early detection of Breast Cancer plays a critical role in decision making. Besides mammography and MRI, ultrasound has been a useful modality in detecting breast tumors. Moreover, the combination with Color Mode significantly reinforces the B-mode diagnosis. Lately, new ultrasound technique, elastography is providing extra information to increase accuracy. However, each one uses different method including compressed and non-compressed technologies. Developing by Siemens, ARFI is a non-compressed elastography, evaluates tissue stiffness base on replacement caused by acoustic radiation force impulse (ARFI).
AIMS:
To evaluate ARFI qualitative and quantitative assessment to differentiate benign and malignant breast tumors.
METHODS and MATERIALS
From April to November 2015, we selected 85 breast lesions classified as category 3-5 according to ACR Breast Imaging Recording and Data System (BI-RADS). Two radiologists analyzed them in ARFI features : Elasticity Score (E.S) which on scales 1-5 (Score 1-3: low suspicion, Score 4-5: high suspect of malignancy), then measure Area Ratio (proportion between VTI lesion area and B-mode area) and set ROI in 5 different points of the lesion then measured Shear-wave Velocity (SWV). Biopsy were required for final diagnosis (FNAC, Core Biopsy, Excisional Biopsy). Exclusion criteria include: Non histopathology confirmation or Male breast lesion.  
RESULT
85 selected breast lesions includes 59 benign (69.4%) and 26 (30.6%) malignant. Lesions appear to dominantly locate in right breast 52/85 (61.2%), left 33/85 (38.8%). The mean size is 16.26 ±6.56 transversely and perpendicularly 9.64 ±5.01 mm. In ES assessment, 26/26 cancer cases were within suspicious range ( ES4-5). The AR cut-off point would best at 1.34 with sensitivity 88.5% and specificity 94.9% (area under ROC curve for malignancy is 0.933). After excluded 8 malignant cases has SWV as X.XX m/s, the best SWV cut-off point is at 2.24 with sensitivity 94.4% and specificity 72.9% (area under ROC curve for malignancy is 0.911).
CONCLUSION
Overall, ARFI is a useful tools for diagnosis and decision of biopsy breast tumors. The technique is simple since it is non-compressed and repeatable. It cannot replaced biopsy but reinforced the Conventional ultrasound  findings. This is a promising technique helps avoiding invasive diagnosis if we use it right and well-combined with other features. 


4/ Ultrasound findings of rib fractures in undetected cases by chest x-rays
Le Thanh Liem MD, Phan Thanh Hai MD
Medic Medical Center, Ho Chi Minh City, Vietnam
Abstract:

OBJECTIVE:

To accumulate experiences of detection of costal cartilage and rib fractures which are negative on X-ray films of  chest trauma patients.

METHODS:

A total of 112 patients at the Medic Medical Center from 2008 to 2015, suffering from chest trauma, detected costal cartilage or rib fractures on chest ultrasound with a 7.5 MHz linear transducer of ultrasound. All patients were examined later by chest X-ray. Statistical analysis was done to outline the ultrasound findings of these rib fractures.

RESULTS:

In 112 patients showed costal cartilage and anterior rib lesions, only 10 patients (9%) showed of rib fracture on chest X-ray film, whereas 102 other patients (91.0%) had no evidence of rib lesions on chest X-ray film. Fracture of the rib with a disruption of continuity of bony cortex, mostly located near the costo-chondral junction. Rib fracture cases that the displacement is minimal, usually detected by longitudinal plane based on accompanied by the soft tissue edema or hematoma around the fracture site. Costal cartilage fractures were in five patients (4,5%). Costal cartilage fracture appeared as disruption of cortex, small echogenic lines in cartilage, and bruised cartilage. In addition to detecting rib fractures, ultrasound helps evaluating the stage of disease based on the presence of hematoma, cartilage callus or bone callus. Some patients may not specify the position localized pain or may not remember history of trauma until there is evidence of ultrasound to confirm the diagnosis.

CONCLUSIONS:

Ultrasonography is a useful imaging modalities in disclosing the rib fractures which were negative on chest X-ray film in chest trauma.
Although no significant change in treatment, but the detection of rib fractures is very helpful in explaining the cause of pain, reducing the anxiety of patients and avoid other unnecessary diagnostic procedures.