MEDIC MEDICAL CENTER and ULTRASOUND DIAGNOSIS in VIETNAM- Dr NGUYỄN QUÝ KHOÁNG

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 (Đóng góp của Medic 1986-2016) BS NGUYỄN QUÝ KHOÁNG

S W ELASTO into PLAQUE IMAGING from E C R 2016

ELASTOGRAPHY OFFERS NEW INSIGHTS INTO PLAQUE IMAGING

ELASTOGRAPHY OFFERS NEW INSIGHTS INTO PLAQUE IMAGING

Elastography has been used for many years to differentiate malignant from benign lesions, especially in the breast or liver. Experience in carotid artery disease is limited, but recent studies have shown that elastography may help to stratify plaque and reduce the risk of unnecessary surgery, as a Greek expert will show during a New Horizons session today at the ECR.

Stroke is one of the leading causes of death in developed countries; one third of cases are fatal and survival can come with considerable disabilities. In Europe alone, experts estimate that there are one million new ischaemic strokes per year and they expect this number to rise by 12% by 2020, as the population ages1. A wide spectrum of carotid artery diseases can lead to stroke, but atherosclerosis accounts for a significant percentage – about 20 to 30% of cases. Stenosis is typically a cause for atherosclerosis and is now being measured using ultrasound in symptomatic patients, who are usually treated with atherectomy. But it is not so clear how asymptomatic patients should be managed, according to Dr. Nikos Liasis, medical director of Affidea Greece, a pan-European medical service provider specialising in diagnostics investigations, clinical laboratories and cancer treatment services. “Despite many randomised clinical trials, there is a surprising lack of consensus regarding the treatment of asymptomatic patients,” he said ahead of his presentation during the session today. There is widespread agreement among physicians that many procedures are probably being performed with risks that are higher than the risk of the actual indications. “Ninety-two per cent of all atherectomies in the U.S. are undertaken in asymptomatic patients. On average, we operate on 16 patients to prevent one stroke in just five years, so we perform surgery on 15 people who may not need it, which is quite a high risk,” he said. The degree of stenosis is not the only predictive parameter for myocardial infarction or stroke. Therefore it has become crucial to be able to understand and stratify plaque morphology. The majority of myocardial infarctions and strokes are actually caused by plaque rupture. Thanks to histological findings, physicians know that unstable, vulnerable plaques, which are prone to rupture and distal embolisation, are those with a large lipid core and intraplaque haemorrhage. Inflammation is also a high risk factor for plaque rupture. Researchers have tried to establish whether it would be suitable to use ultrasound in everyday clinical practice to stratify plaque morphology, but the results combined with histopathological findings were poor. Liasis and his team at Affidea Greece, together with the University of Athens Medical School and the National Technical University of Athens, decided to conduct a prospective study in order to determine the contribution of ultrasound elastography to the description of plaque morphology. “Ultrasound elastography is based on the principle that so tissue deforms more than hard tissue. So plaques that are hard and stable deform less than so, vulnerable plaques,” he said. So far the few available papers on the topic focused on either shear wave or strain elastography. In his study, Liasis has compared both techniques against histopathological findings and he will present his results today. He estimates that the potential of both techniques for stratifying plaque is significant, and that they may be complementary in many ways as they offer information that is not accessible through B mode or Doppler flow and other US techniques. “Elastography enables the detection of the fibrous cap, the thickness or thinness of which is an indication of plaque instability, but it remains challenging to spot with traditional ultrasound. It also provides information about plaque smoothness and more accurate information on what is outside of the plaque. We have all the features that are characteristics of plaque morphology and which make plaque unstable,” he said. Elastography offers other benefits to consider for daily practice; it is radiation free, accessible and widely available. Furthermore, it does not require any patient preparation and the costs are low. Examination times are short compared with MRI and, unlike CT, there are no allergy risks linked to contrast agents use. However a number of technical limitations remain to be overcome and reproducibility is still challenging. “When plaque is calcified, we are not able to describe it because of the acoustic shadow. Our biggest disadvantage is subjectivity. Reproducibility is still an issue, but using appropriate examination protocols may help,” Liasis said. It will also be necessary to adapt the technique, which has been developed for lesions in superficial organs, to small pulsating vessels. “We need more prospective studies to evaluate its potential. US elastography in carotid plaque imaging is only a few years old. But our research is very promising to describe plaque,” he concluded.

1 Data gathered by Brainomix, Oxford University h‑ps://ec.europa.eu/easme/en/ sme/4065/brainomix-limited BY MÉLISANDE ROUGER 

ARFI CÁC TUYẾN BỌT VÀ TUYẾN GIÁP ở MEDIC CENTER

ARFI CÁC TUYẾN BỌT và TUYẾN GIÁP ở MEDIC CENTER

  

Gần đây siêu âm đàn hồi bắt đầu được áp dụng vào lâm sàng để khảo sát u, bệnh tự miễn và bệnh nhiễm trùng của tuyến giáp và các tuyến bọt.

Những khảo sát riêng lẽ về siêu âm đàn hồi của  tuyến giáp và các tuyến bọt ghi nhận không có khác biệt theo tuổi và phái tính ở người trưởng thành. Tuy nhiên khảo sát siêu âm đàn hồi tuyến giáp và các tuyến bọt trong điều kiện bình thường và khảo sát  cùng lúc và trên cùng người được khám thì chưa có thông tin.

 Chúng tôi có ý định:

1/ tìm tương quan độ sinh echo của tuyến giáp và các tuyến bọt.

2/ tìm khác biệt giữa sinh echo tuyến giáp và tuyến mang tai trên cùng cá thể.

3/ định lượng độ đàn hồi tuyến giáp và các tuyến bọt .

Qua khảo sát 68 [34 nam, 34 nữ] cá nhân cùng lúc tuyến giáp và các tuyến bọt trong tình trạng khỏe mạnh, chúng tôi có kết quả như sau :

Giá trị trung bình vận tốc của sóng biến dạng ở mô tuyến giáp là = 1,58 ± 0,17m/s [ở nghiên cứu của NPB Quân và cs là:1,47 ± 0,41 m/s. Không có sự khác biệt vận tốc này với nhóm tuổi, nhưng có khác biệt với giới (p nhỏ hơn 0,05)].

Giá trị trung bình vận tốc của sóng biến dạng ở mô tuyến dưới hàm bình thường là 1,47± 0,015m/s [ ở nghiên cứu của AF Badea là =1,82 ± 0,41m/s cho cả 2 tuyến P và T].

Giá trị trung bình vận tốc của sóng biến dạng ở mô tuyến mang tai bình thường là 1,42 ± 0,015m/s  so với 1,54 ± 0,6 m/s ở nghiên cứu của I.Badea].

Khác biệt về độ đàn hồi tuyến giáp bình thường và các tuyến mang tai và dưới hàm không có ý nghĩa thống kê ( p nhỏ hơn 0,0001).

Tài liệu tham khảo chính:

Nguyễn Phước Bảo Quân, Nguyễn Hữu Thịnh: Bước đầu nghiên cứu siêu âm đàn hồi mô tuyến giáp ở người bình thường bằng phương pháp tạo hình và đo vận tốc sóng biến dạng qua kỹ thuật ARFI

Alexandru Florin Badea, Attila Tamas Szora, Elisabeta Ciuleanu, Ioana Chioreanu, Grigore Băciuţ, Monica Lupşor Platon, Radu Badea: ARFI quantitative elastography of the submandibular glands. Normal

measurements and the diagnosis value of the method in radiation submaxillitis.

Iulia Badea, Attila Tamas-Szora, Ioana Chiorean, Maria Crisan, Elisabeta Ciuleanu, Grigore Baciut, Mindra Badea: Acoustic Radiation Force Impulse quantitative elastography: a new  noninvasive technique for the evaluation of parotid glands.  A preliminary study in controls and in patients with irradiated nasopharyngeal carcinoma.

SHEAR WAVE ELASTOGRAPHY from APLIO 500 TOSHIBA on LIVER FIBROSIS

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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.

ULTRASOUND for D V T CAUSE a PULMONARY EMBOLISM

ULTRASOUND for D V T CAUSE a P E

http://www.auntminnie.com/index.aspx?sec=sup&sub=ult&pag=dis&ItemID=113323

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 Touch^TM 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

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.