- Email: [email protected]
0483: Leprosy - Ultrasound Evaluation of Peripheral Nerves
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Ultrasound in Medicine and Biology
bleeding has not been prospectively validated and need not automatically result in obtaining tissue for histologic evaluation. 0478 The Value of 3D Ultrasound in Women with Postmenopausal Bleeding Povilas Sladkevicius, Departement of Obstetrics and Gynecology, Malmo¨ University Hospital, Lund University, Malmo¨, Sweden Aim: The aim was to assess the value of three-dimensional (3D) ultrasound to distinguish between benign and malignant endometrium in women with postmenopausal bleeding (PMB). Methods: 62 patients with PMB and endometrial thickness ⬎4.5 mm underwent transvaginal 3D ultrasound examination. The volume, vascularization index (VI), flow index (FI), and vascularization-flow index (VFI) were calculated for the endometrium and a 2 mm “shell” surrounding the endometrium using VOCALTM software. Histological diagnosis was obtained. Receiver operating characteristic (ROC) curves were drawn to evaluate an ability of measurements to distinguish between benign and malignant endometrium. Logistic regression analysis was used to predict endometrial malignancy. Results: There were 49 benign and 13 malignant endometria. Endometrial thickness and volume were larger and flow indices were higher both in the endometrium and in the endometrial shell in malignant endometria than in benign endometria (p⬍0.05). The best cut-ff value for endometrial thickness to predict malignancy was 11.8 mm (sensitivity 0.85, specificity 0.71, LR⫹ 3.0, LR- 0.2). Endometrial thickness had an area under the ROC curve of 0.82. The best logistic regression model to predict malignancy contained endometrial thickness (odds ratio 1.2, p⬍0.009) and VI in the endometrial shell (odds ratio 1.1, p⬍0.016) as predicting variables. The area under the ROC curve for the best logistic regression model was 0.86, and the best risk cut-off for this model (0.22) had a sensitivity of 0.69, a specificity of 0.86, LR⫹ 4.8, LR- 0.4. Conclusions: The diagnostic accuracy of 3D ultrasound was only marginally superior to that of endometrial thickness. 0479 Anterior Hip and Iliopsoas Apparatus Assessment Stephen Bird, Benson Radiology, Australia The iliopsoas apparatus will be discussed from the level of the inguinal ligament to its distal insertion. Sonographic differentiation of the individual muscle belly fibre components will be described as well as common pathological patterns. The iliopsoas bursa and injection/ aspiration techniques will be discussed. The iliopsoas tendon insertion onto the lesser trochanter is an area which is traditionally difficult to assess with ultrasound. A variety of factors including anisotropy, deep location and poor quality acoustic window through muscle belly edges result in a technical challenge. A method of sonographic assessment using the adductor longus and pectineus muscle bellies as an acoustic window will be described allowing high resolution assessment of the tendon insertion and musculotendinous junction. The anterior hip labrum will be briefly discussed with particular reference made to the association between labral abnormalities and femoro-acetabular impingement. 0481 Ultrasound Guided Tendonopathy Treatment Options Phil Lucas, PRP Diagnostic Imaging, Australia The spectrum of ultrasound guided procedures for treatment of tendinopathy will be presented. The advantages and disadvantages and
Volume 35, Number 8S, 2009 limited evidence in the literature as to the therapeutic success of these treatments will be discussed. These treatments include, peritendinous and bursal corticosteroid injections, dry needling and fenestration, prolotherapy, autologous blood and plasma injections, polidocanol injections and ultrasound guided lithotripsy. 0482 The Clinic Value of High Frequency Ultrasound in Diagnosis of Peripheral Nerve Diseases Luyao Zhou, Department of Medical Ultrasonics, The First Affiliated Hospital, Sun Yat-Sen University, China Xiaoyan Xie, Department of Medical Ultrasonics, The First Affiliated Hospital, Sun Yat-Sen University, China Erjiao Xu, China Objective: To evaluate the clinical value of high frequency ultrasound in diagnosing peripheral nerve diseases (PNDs). Methods: From January 2003 to December 2006, 64 cases of PNDs were analyzed retrospectively. The ultrasound diagnosis was compared with the operative and pathological diagnosis. Results: Based on the operative and histopathological results, in 38 patients with trauma or entrapment, 38 among 45 traumatic nerves were rightly diagnosed by ultrasound. The coincidence rate was 84.4%(38/ 45). In 26 patients with original peripheral nerve tumors(PNTs), including 20 neurilemomas, 4 neurofibromas and 2 malignant neurilemomas, 16 cases were diagnosed correctly by ultrasound with a coincidence rate of 61.5%(16/26). The coincidence rates in limbs and trunk were 86.7%(13/15) and 27.3%(3/11), respectively. Conclusion: The study suggests that high frequency ultrasound can locate peripheral nerve trauma precisely, assess the impair degree correctly and provide useful information for clinic diagnosis. The high frequency ultrasound brings better diagnosis outcome in limbs nerve tumors than in trunk. 0483 Leprosy - Ultrasound Evaluation of Peripheral Nerves Praveen LN Thummalakunta, Abhishek’s Institute of Imageology, India Laxmi NA Thummalakunta, Abhishek’s Institute of Imageology, United States Surekha Thummalakunta, Abhishek’s Institute of Imageology, India Lakshmi R Beeravolu, Abhishek’s Institute of Imageology, United States Introduction: Ultrasound (US) evaluation of peripheral nerves in leprosy is used to assess the severity of the condition, progress of the disease and response to the treatment. Materials & Methods: 16 patients were evaluated from September 2007 to April 2008, had 3 women and 13 men; age range 12–52 years, mean 29.4⫾10.3 years. The diagnosis of leprosy was based on established clinical, bacteriological and histopathological criteria. A control group of 28 normal individuals were evaluated for comparison. A total of 58 nerves, including 20 ulnar (UN), 13 median (MN) and 25 posterior tibial (PTN) nerves, were examined. Sequoia, Acuson, and Voluson Expert 730 were used. US image analysis was based on measurement of the maximum cross-sectional area of the nerve, analysis of nerve echo texture, identification of peri-neural tissue and detection of endoneural colour flow signals. Results: Peripheral nerve was considered normal with size of ⬍ 11 sq.mm, echogenic peri-neural tissue, well-defined similar sized fascicles and inter-fascicular epineurium. The characteristic US features were increase in the size of the nerve, peri-neural oedema, decrease/ loss of fascicles, increased peri-neural and intra-neural colour flow.
Abstracts Response to treatment was evidenced by decrease in size, normal to echogenic peri-neural tissue, reversal of fascicular pattern and very low colour flow pattern was demonstrated. Discussion: Ultrasound features are very useful in establishing the diagnosis and following patients after treatment. US evaluation of peripheral nerve involvement is easy, cost-effective and well accepted by the patients. 0487 Reflux Changes at the Saphenofemoral Junction Following Endovenous Laser Obliteration of the Great Saphenous Vein Anne C Carter, Vascular Investigations, Mornington, Australia George M Somjen, Vascular Investigations, Mornington, Australia Avinesh Naicker, Vascular Investigations, Mornington, Australia Graeme C Last, Vascular Investigations, Mornington, Australia Wai-Leng Chue, Vascular Investigations, Mornington, Australia Objective: The objective of the study was to examine reflux changes in the proximal great saphenous vein (GSV) after endovenous laser treatment. Methods: In a one year period in 2007, 172 patients (208 legs) underwent endovenous laser obliteration of the GSV. Follow up duplex scan studies were undertaken at 3 weeks, 6 months and 1 year after the intervention. The extent of vein obliteration and the presence of reflux in the proximal GSV were investigated. Results: The GSV was successfully obliterated in 204 legs (98%). In 80% the saphenofemoral junction (SFJ) remained open, and the GSV was found obliterated only below the subterminal valve. In most of these extremities the patent proximal segment of the GSV was competent and assisted the physiological drainage of the proximal abdominal tributaries towards the SFJ. After one year the SFJ and the patent proximal GSV remained free of reflux in the majority of cases. Partial or full recanalisation of a previously obliterated GSV occurred in nine patients. There was no ultrasound evidence of neovascularisation at the SFJ. Recurrent reflux was mostly associated with anterior accessory saphenous vein incompetence. Conclusion: Following endovenous laser obliteration the very proximal segment of the GSV stays patent and competent in the majority of cases. The venous drainage from the lower abdominal wall towards the SFJ remains undisturbed. Longer term observations are needed to evaluate the clinical significance of a persistent or newly appearing incompetence at the SFJ. 0491 Elastography for the Characterization of Nonpalpable Breast Lesions Woo Kyung Moon, Seoul National University Hospital, Korea We performed several prospective clinical studies to evaluate the role of sonoelastography for the characterization of nonpalpable breast lesions. First, 842 consecutive women who were scheduled to undergo USguided core biopsy due to 864 breast lesions(79 cancers and 785 benign lesions) detected by supplemental screening US were examined with a commercialized sonoelastography. For the BI-RADS category 4a lesions, 28.5% (216 of 757) had a normal strain and 99.1% (214 of 216) of lesions with normal strain found out to be benign. Second, 300 women with 339 nonpalpable lesions were prospectively examined with sonoelastograpy and color Doppler US (CDUS) prior to biopsy. Of the 301 lesions with BI-RADS category 4a, 76 (25%) lesions showed normal strain on elastography and no vascularity on CDUS and all of them were found to be benign. Breast lesions diagnosed with DCIS by US-guided core biopsy with invasive components
S67
at surgery show less strain than pure DCIS at elastography regardless of the lesion size and B-mode US findings. Third, we evaluated the accuracy of neural network analysis of elastographic features at sonoelastography for the classification of 113 benign and 68 malignant breast tumors. Az values of the three elastographic features- mean (0.87), median (0.86) and mode (0.83)-were significantly higher than the Az values for the six B-mode features (0.54-0.69). In conclusion, addition of elastography to breast US has potential to reduce benign biopsy for BIRADS category 3 or 4a lesions that are detected by supplemental screening US. 0493 Value of Modified Elasticity Scoring System in the Diagnosis of Solid Breast Lesions Xiaoyun Xiao, Department of Ultrasound, Second Affiliated Hospital of Sun Yat-Sen University, China Hui Zhi, Department of Ultrasound, Second Affiliated Hospital of Sun Yat-Sen University, China Haiyun Yang, Department of Ultrasound, Second Affiliated Hospital of Sun Yat-Sen University, China Bing Ou, Department of Ultrasound, Second Affiliated Hospital of Sun Yat-Sen University, China Yanling Wen, Department of Ultrasound, Second Affiliated Hospital of Sun Yat-Sen University, China Baoming Luo, Department of Ultrasound, Second Affiliated Hospital of Sun Yat-Sen University, China Objective: The purpose of the study was to evaluate the value of modified elasticity scoring system in the diagnosis of solid breast lesions. Methods: From September 2004 to August 2007, ultrasound strain imaging was performed on 575 patients with 626 solid lesions. All the breast lesions were analyzed with established and modified elasticity scoring system respectively. The established scoring system was the one proposed by Itoh A et al in 2004. The established one was proposed by our department. The diagnostic results were compared with histopathologic results. Receiver operating characteristic curves (ROC) were computed individually. The areas under the ROC (AUC) were calculated and compared. Results: There were 242 malignant and 384 benign lesions. 527 lesions could be scored according to both scoring systems. 99 lesions with untypical elasticity images could only be scored with modified scoring system. For the 527 lesions, AUC (area under ROC curve) of established elasticity scoring system was 0.914 and that of modified elasticity scoring system was 0.963. The difference between them was statistically significant. (Z⫽5.029, P⬍0.001) For 99 lesions, the AUC was 0.967 by using modified elasticity scoring system. Conclusions: Compared with the established one, modified elasticity scoring system is more accurate in the differential diagnosis of solid breast lesions. The system is convenient to handle and may be substitution for the established one. Since the limitation of UE, it’s better to combine it with 2-D ultrasound for the differential diagnosis. 0494 Ultrasound (US) - Elastography of Suspicious Abnormal Breast Lesions Detected by Supplemental Screening US Woo Kyung Moon, Seoul National University Hospital, Korea Nariya Cho, Seoul National University Hospital, Korea Purpose: To find out whether elastography is helpful in reducing the number of benign biopsies, using histological analysis as a reference standard.
Ultrasound in Medicine and Biology
bleeding has not been prospectively validated and need not automatically result in obtaining tissue for histologic evaluation. 0478 The Value of 3D Ultrasound in Women with Postmenopausal Bleeding Povilas Sladkevicius, Departement of Obstetrics and Gynecology, Malmo¨ University Hospital, Lund University, Malmo¨, Sweden Aim: The aim was to assess the value of three-dimensional (3D) ultrasound to distinguish between benign and malignant endometrium in women with postmenopausal bleeding (PMB). Methods: 62 patients with PMB and endometrial thickness ⬎4.5 mm underwent transvaginal 3D ultrasound examination. The volume, vascularization index (VI), flow index (FI), and vascularization-flow index (VFI) were calculated for the endometrium and a 2 mm “shell” surrounding the endometrium using VOCALTM software. Histological diagnosis was obtained. Receiver operating characteristic (ROC) curves were drawn to evaluate an ability of measurements to distinguish between benign and malignant endometrium. Logistic regression analysis was used to predict endometrial malignancy. Results: There were 49 benign and 13 malignant endometria. Endometrial thickness and volume were larger and flow indices were higher both in the endometrium and in the endometrial shell in malignant endometria than in benign endometria (p⬍0.05). The best cut-ff value for endometrial thickness to predict malignancy was 11.8 mm (sensitivity 0.85, specificity 0.71, LR⫹ 3.0, LR- 0.2). Endometrial thickness had an area under the ROC curve of 0.82. The best logistic regression model to predict malignancy contained endometrial thickness (odds ratio 1.2, p⬍0.009) and VI in the endometrial shell (odds ratio 1.1, p⬍0.016) as predicting variables. The area under the ROC curve for the best logistic regression model was 0.86, and the best risk cut-off for this model (0.22) had a sensitivity of 0.69, a specificity of 0.86, LR⫹ 4.8, LR- 0.4. Conclusions: The diagnostic accuracy of 3D ultrasound was only marginally superior to that of endometrial thickness. 0479 Anterior Hip and Iliopsoas Apparatus Assessment Stephen Bird, Benson Radiology, Australia The iliopsoas apparatus will be discussed from the level of the inguinal ligament to its distal insertion. Sonographic differentiation of the individual muscle belly fibre components will be described as well as common pathological patterns. The iliopsoas bursa and injection/ aspiration techniques will be discussed. The iliopsoas tendon insertion onto the lesser trochanter is an area which is traditionally difficult to assess with ultrasound. A variety of factors including anisotropy, deep location and poor quality acoustic window through muscle belly edges result in a technical challenge. A method of sonographic assessment using the adductor longus and pectineus muscle bellies as an acoustic window will be described allowing high resolution assessment of the tendon insertion and musculotendinous junction. The anterior hip labrum will be briefly discussed with particular reference made to the association between labral abnormalities and femoro-acetabular impingement. 0481 Ultrasound Guided Tendonopathy Treatment Options Phil Lucas, PRP Diagnostic Imaging, Australia The spectrum of ultrasound guided procedures for treatment of tendinopathy will be presented. The advantages and disadvantages and
Volume 35, Number 8S, 2009 limited evidence in the literature as to the therapeutic success of these treatments will be discussed. These treatments include, peritendinous and bursal corticosteroid injections, dry needling and fenestration, prolotherapy, autologous blood and plasma injections, polidocanol injections and ultrasound guided lithotripsy. 0482 The Clinic Value of High Frequency Ultrasound in Diagnosis of Peripheral Nerve Diseases Luyao Zhou, Department of Medical Ultrasonics, The First Affiliated Hospital, Sun Yat-Sen University, China Xiaoyan Xie, Department of Medical Ultrasonics, The First Affiliated Hospital, Sun Yat-Sen University, China Erjiao Xu, China Objective: To evaluate the clinical value of high frequency ultrasound in diagnosing peripheral nerve diseases (PNDs). Methods: From January 2003 to December 2006, 64 cases of PNDs were analyzed retrospectively. The ultrasound diagnosis was compared with the operative and pathological diagnosis. Results: Based on the operative and histopathological results, in 38 patients with trauma or entrapment, 38 among 45 traumatic nerves were rightly diagnosed by ultrasound. The coincidence rate was 84.4%(38/ 45). In 26 patients with original peripheral nerve tumors(PNTs), including 20 neurilemomas, 4 neurofibromas and 2 malignant neurilemomas, 16 cases were diagnosed correctly by ultrasound with a coincidence rate of 61.5%(16/26). The coincidence rates in limbs and trunk were 86.7%(13/15) and 27.3%(3/11), respectively. Conclusion: The study suggests that high frequency ultrasound can locate peripheral nerve trauma precisely, assess the impair degree correctly and provide useful information for clinic diagnosis. The high frequency ultrasound brings better diagnosis outcome in limbs nerve tumors than in trunk. 0483 Leprosy - Ultrasound Evaluation of Peripheral Nerves Praveen LN Thummalakunta, Abhishek’s Institute of Imageology, India Laxmi NA Thummalakunta, Abhishek’s Institute of Imageology, United States Surekha Thummalakunta, Abhishek’s Institute of Imageology, India Lakshmi R Beeravolu, Abhishek’s Institute of Imageology, United States Introduction: Ultrasound (US) evaluation of peripheral nerves in leprosy is used to assess the severity of the condition, progress of the disease and response to the treatment. Materials & Methods: 16 patients were evaluated from September 2007 to April 2008, had 3 women and 13 men; age range 12–52 years, mean 29.4⫾10.3 years. The diagnosis of leprosy was based on established clinical, bacteriological and histopathological criteria. A control group of 28 normal individuals were evaluated for comparison. A total of 58 nerves, including 20 ulnar (UN), 13 median (MN) and 25 posterior tibial (PTN) nerves, were examined. Sequoia, Acuson, and Voluson Expert 730 were used. US image analysis was based on measurement of the maximum cross-sectional area of the nerve, analysis of nerve echo texture, identification of peri-neural tissue and detection of endoneural colour flow signals. Results: Peripheral nerve was considered normal with size of ⬍ 11 sq.mm, echogenic peri-neural tissue, well-defined similar sized fascicles and inter-fascicular epineurium. The characteristic US features were increase in the size of the nerve, peri-neural oedema, decrease/ loss of fascicles, increased peri-neural and intra-neural colour flow.
Abstracts Response to treatment was evidenced by decrease in size, normal to echogenic peri-neural tissue, reversal of fascicular pattern and very low colour flow pattern was demonstrated. Discussion: Ultrasound features are very useful in establishing the diagnosis and following patients after treatment. US evaluation of peripheral nerve involvement is easy, cost-effective and well accepted by the patients. 0487 Reflux Changes at the Saphenofemoral Junction Following Endovenous Laser Obliteration of the Great Saphenous Vein Anne C Carter, Vascular Investigations, Mornington, Australia George M Somjen, Vascular Investigations, Mornington, Australia Avinesh Naicker, Vascular Investigations, Mornington, Australia Graeme C Last, Vascular Investigations, Mornington, Australia Wai-Leng Chue, Vascular Investigations, Mornington, Australia Objective: The objective of the study was to examine reflux changes in the proximal great saphenous vein (GSV) after endovenous laser treatment. Methods: In a one year period in 2007, 172 patients (208 legs) underwent endovenous laser obliteration of the GSV. Follow up duplex scan studies were undertaken at 3 weeks, 6 months and 1 year after the intervention. The extent of vein obliteration and the presence of reflux in the proximal GSV were investigated. Results: The GSV was successfully obliterated in 204 legs (98%). In 80% the saphenofemoral junction (SFJ) remained open, and the GSV was found obliterated only below the subterminal valve. In most of these extremities the patent proximal segment of the GSV was competent and assisted the physiological drainage of the proximal abdominal tributaries towards the SFJ. After one year the SFJ and the patent proximal GSV remained free of reflux in the majority of cases. Partial or full recanalisation of a previously obliterated GSV occurred in nine patients. There was no ultrasound evidence of neovascularisation at the SFJ. Recurrent reflux was mostly associated with anterior accessory saphenous vein incompetence. Conclusion: Following endovenous laser obliteration the very proximal segment of the GSV stays patent and competent in the majority of cases. The venous drainage from the lower abdominal wall towards the SFJ remains undisturbed. Longer term observations are needed to evaluate the clinical significance of a persistent or newly appearing incompetence at the SFJ. 0491 Elastography for the Characterization of Nonpalpable Breast Lesions Woo Kyung Moon, Seoul National University Hospital, Korea We performed several prospective clinical studies to evaluate the role of sonoelastography for the characterization of nonpalpable breast lesions. First, 842 consecutive women who were scheduled to undergo USguided core biopsy due to 864 breast lesions(79 cancers and 785 benign lesions) detected by supplemental screening US were examined with a commercialized sonoelastography. For the BI-RADS category 4a lesions, 28.5% (216 of 757) had a normal strain and 99.1% (214 of 216) of lesions with normal strain found out to be benign. Second, 300 women with 339 nonpalpable lesions were prospectively examined with sonoelastograpy and color Doppler US (CDUS) prior to biopsy. Of the 301 lesions with BI-RADS category 4a, 76 (25%) lesions showed normal strain on elastography and no vascularity on CDUS and all of them were found to be benign. Breast lesions diagnosed with DCIS by US-guided core biopsy with invasive components
S67
at surgery show less strain than pure DCIS at elastography regardless of the lesion size and B-mode US findings. Third, we evaluated the accuracy of neural network analysis of elastographic features at sonoelastography for the classification of 113 benign and 68 malignant breast tumors. Az values of the three elastographic features- mean (0.87), median (0.86) and mode (0.83)-were significantly higher than the Az values for the six B-mode features (0.54-0.69). In conclusion, addition of elastography to breast US has potential to reduce benign biopsy for BIRADS category 3 or 4a lesions that are detected by supplemental screening US. 0493 Value of Modified Elasticity Scoring System in the Diagnosis of Solid Breast Lesions Xiaoyun Xiao, Department of Ultrasound, Second Affiliated Hospital of Sun Yat-Sen University, China Hui Zhi, Department of Ultrasound, Second Affiliated Hospital of Sun Yat-Sen University, China Haiyun Yang, Department of Ultrasound, Second Affiliated Hospital of Sun Yat-Sen University, China Bing Ou, Department of Ultrasound, Second Affiliated Hospital of Sun Yat-Sen University, China Yanling Wen, Department of Ultrasound, Second Affiliated Hospital of Sun Yat-Sen University, China Baoming Luo, Department of Ultrasound, Second Affiliated Hospital of Sun Yat-Sen University, China Objective: The purpose of the study was to evaluate the value of modified elasticity scoring system in the diagnosis of solid breast lesions. Methods: From September 2004 to August 2007, ultrasound strain imaging was performed on 575 patients with 626 solid lesions. All the breast lesions were analyzed with established and modified elasticity scoring system respectively. The established scoring system was the one proposed by Itoh A et al in 2004. The established one was proposed by our department. The diagnostic results were compared with histopathologic results. Receiver operating characteristic curves (ROC) were computed individually. The areas under the ROC (AUC) were calculated and compared. Results: There were 242 malignant and 384 benign lesions. 527 lesions could be scored according to both scoring systems. 99 lesions with untypical elasticity images could only be scored with modified scoring system. For the 527 lesions, AUC (area under ROC curve) of established elasticity scoring system was 0.914 and that of modified elasticity scoring system was 0.963. The difference between them was statistically significant. (Z⫽5.029, P⬍0.001) For 99 lesions, the AUC was 0.967 by using modified elasticity scoring system. Conclusions: Compared with the established one, modified elasticity scoring system is more accurate in the differential diagnosis of solid breast lesions. The system is convenient to handle and may be substitution for the established one. Since the limitation of UE, it’s better to combine it with 2-D ultrasound for the differential diagnosis. 0494 Ultrasound (US) - Elastography of Suspicious Abnormal Breast Lesions Detected by Supplemental Screening US Woo Kyung Moon, Seoul National University Hospital, Korea Nariya Cho, Seoul National University Hospital, Korea Purpose: To find out whether elastography is helpful in reducing the number of benign biopsies, using histological analysis as a reference standard.