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Lesiones Hepaticas Focales Malignas
Tuesday, March 24 SPECIAL INTEREST SESSIONS, 8:15 AM – 10:15 AM Clinical Applications of Ultrasound Contrast: Part 1
Ultrasonido en Intervencionismo Hep atico. Interventional Ultrasound in Liver Jorge Rabat Surgery, Fremantle Hospital, Bolivar, Bolivar, Venezuela, Bolivarian Republic Of
Moderator: Urike Hamper, MD, MBA In the United States, ultrasound contrast agents are approved only for cardiac use. This session will review the WFUMB guidelines and explain how we in the United States can incorporate contrast-enhanced ultrasound (CEUS) into daily practice. The value of CEUS as an everyday problem-solving tool, especially for liver and genitourinary imaging, will be discussed.
El Ultrasonido se ha convertido en una herramienta diagn ostica imprescindible en la medicina del siglo XXI y ademas una alternativa de primera lınea para orientar procedimientos diagn osticos y terapeuticos. Presenta importantes ventajas como guıa de procedimientos: es barata, disponible, m ovil, no utiliza radiaciones ionizantes y requiere menos tiempo que otras tecnicas. El metodo puede realizarse usando dispositivos adaptados a las sondas o mediante la tecnica de manos libres (sosteniendo la aguja con una mano y la sonda con la otra). La realizaci on de procedimientos guiados por ecografıa requiere una planificaci on previa cuidadosa, tener una hemostasia suficiente o que la zona de punci on sea directamente compresible, obtener el consentimiento informado del paciente, y medidas de asepsia y anestesia apropiadas. Una serie de organos son susceptibles a esta tecnica, dentro de los mas comunes esta el hıgado. La tecnica de los procedimientos supone introducir la aguja o el cateter a traves del plano de corte del ec ografo. El avance se controla en tiempo real, pudiendo dirigir la aguja hasta la zona blanco seleccionado. Los procedimientos mas habituales incluyen citologıas, biopsias, drenajes e inyecciones percutaneas y aplicaci on de Radiocirugıa.. El drenaje supone casi siempre colocar un cateter en una colecci on. Puede hacerse usando las tecnicas de Seldinger, tr ocar o mediante cateteres diversos. Las complicaciones son muy pocas e incluyen sangrado, infecci on, lesiones de vıscera hueca, etc. Un Capıtulo aparte es el Ultrasonido Endosc opico Intervencionista.
Ultrasonido General (In Spanish) Moderator: Tulio Augusto Alves Macedo, MD Elastografıa Hepatica Leandro Fernandez Laboratorio de Ecografia Avanzada, Caracas, VENEZUELA, BOLIVARIAN REPUBLIC OF La palpacion para estimar la dureza de una lesi on era un metodo de diagn ostico practicado en Egipto en 2600 AC y la Elastografıa ofrece una ‘‘palpacion virtual’’. Esta tecnica proporciona una representacion visual de la informacion tactil obtenida por palpacion fısica del tejido. Basado en el trabajo de Ophir et al, la industria comenzo a desarrollar los instrumentos adecuado para hacer este tipo de estudio es posible. Al mismo tiempo, los investigadores clınicos comenzaron a validar los resultados obtenidos mediante el uso de este proceso. La imagen es el resultado de la comparacion matematica entre la rigidez de la lesion rodeada por tejido normal. Para una mejor comprension, debemos definir algunos terminos; Elasticidad: capacidad de un objeto para deformarse bajo presion. Rigidez: incapacidad para deformarse bajo presion. Tension: cantidad de deformacion del tejido. Fuente de Compresion: es la forma c omo se ejerce la fuerza para comprimir el tejido Hay diferentes tipos de Elastografıa, que han sido utilizadas en el tiempo: Transitoria, Tension en Tiempo Real y Cuantitativa como ARFI y Shear Wave. Para la evaluacion de fibrosis hepatica y neoplasias, estas ultimas han demostrado tener mejores resultados. Las tecnicas cuantitativas ofrecen valores especıficos que mejoran la reproductibilidad del metodo. Sus valores se expresan en metros/segundo o kilopascales. El metodo es altamente efectivo y de acuerdo a sus resultados puede decidirse en la mayorıa de los pacientes si es necesaria o no, la realizacion de biopsia hepatica. __________________________________________________ ____ Sporea Ioan. Hepatic Elastography Using Ultrasound Waves. DOI 10.2174/97816080546331120101. eISBN: 978-160805-463-3 Ferraioli G et al. Accuracy of Real-Time Shear Wave Elastography for Assessing Liver Fibrosis in Chronic Hepatitis C: A Pilot Study. Hepatology. Vol. 56(6): 2125-33. 2012
Lesiones Hepaticas Focales Malignas Maria Cristina Chammas Radiology, University of Sao Paulo, Sao Paulo, Sao Paulo, Brazil LEARNING OBJECTIVES To discuss the basics of ultrasound diagnosis of malignant focal liver lesions (FLL). To present the main standards of FLL on B-mode US and the vascular patterns of lesions (Doppler US and CEUS). How to describe the malignant FLL. To learn about the potential value as well as the limitations of Contrast Enhanced Ultrasound (CEUS) in FLL. The diagnosis of malignant focal liver lesions is based on the association of clinical findings and ultrasound findings (both B-mode and in the vascularization pattern of these lesions). The main questions to be answered are: this finding is incidental in a healthy patient or the focal lesion is part of a broader framework Regarding to clinical features, the main issues are: the injury is incidental in a healthy patient or the FLL is part of the one clinical presentation, as monitoring cancer treatment, infectious or if the patient has a chronic liver disease, in follow up of hepatocellular carcinoma (HCC). What symptoms are present: fever, consuptivo context, etc. Concerning previous treatments: must also be searched. Presentation of typical pattern and enhancement patterns of various histologic types of malignant FLL on B-mode and Contrast Enhanced
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Abstracts
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Ultrasound (CEUS), respectively. Explanation of their hemodynamic behaviour post contrast injection based on their histology and recognition of atypical patterns of contrast enhancement. The main malignant FLLs will be presented (cases of the HCC and metastases). Since the FLL is present, how to describe the main findings of the lesions is essential. FLL should be characterized as the location (segment), number of lesions( if 3 or more nodules), size (at least 2 axes), echotexture, echogenicity, presence of necrosis / calcification / perinodular halo. Margin: regularity / definition. Besides these findigns, it is very important characterize if there is vascular infiltration / thrombosis (portal vein, hepatic veins, ICV). If there is thrombosis of the portal system: staging it is helpful (give affected segments, extension). Another point is trying to define the thrombosis origin (hematogenous or tumoral). Presence of dilatation of the bile ducts must be reported, and ascites as well. The pattern of liver parenchyma must be reported: chronic liver disease or not / volume redistribution and other signs of cirrhosis.
clinical guidelines, not always provides the desired results and maintains a considerable incidence of cardiorespiratory insufficiency. Echocardiography can council us on these patients’ clinical handling, not only the initial fluid therapy but also on the best-suited election of the vasoactive/inotropic treatment and the early detection of complications. It contributes as well to improving the etiological diagnosis, allowing one to know the heart performance with more precision. The parameters that are evaluated cardiac function, ejection fraction, and Cardiac Output index, systolic volume. The Pre-load: Ventricular size, diameter of the inferior vena cava (IVC). Post-load: Peripheral Vascular Resistance Anatomy: pericardial fluid with or without tamponade. Probably is the time that hemodinamic monitoring guided by Ultrasound be generalized in all ICUs
Hands-on Scanning: Peripheral Nerves of the Upper Extremity
Concomitant Entities During Gestation: Is There a Mole Among Us? Margaret Dziadosz New York University, New York, New Jersey, United States
Moderators: Kenneth Lee, MD, Humberto Rosas, MD On completion of this session, participants will have gained hands-on experience in scanning the periperal nerves of the upper extremity.
Nonfetal Obstetric Ultrasound Moderator: Ana Monteagudo, MD
Moderators: Dean Nakamoto, MD, Cornnie Deurdulian, MD
It is estimated that 1/22,000 – 1/100,000 gestations will have a concomitant molar gestation present. Increased first trimester surveillance allows further diagnosis but also opens a pandoras box of differential diagnosis including that of subchorionic hematoma and placental mesencymal dysplasia. Definitive diagnosis has significant implications for patient counseling and potential for morbid outcomes. Normal sonographic placental appearance, concomitant molar gestations and sonographic differentials will be presented in addition to a brief commentary on clinical significance of abnormal findings.
After attending this session, participants will be able to identify some common as well as uncommon complications during interventional procedures. They will also understand how to avoid possible complications and ways to manage them once the complications do occur.
Beyond the placenta: Amniotic fluid, umbilical cord and cervix Jonathan Rosner OB/GYN, Division of MFM, NYU Langone Medical Center , New York, New York, United States
Know When to Hold ’Em: How to Avoid Complications During Interventional Procedures and How to Manage When You Get Them
New Horizons in Critical Care: Part 1 Moderator: Eitan Dickman, MD, RDMS Update in Clinician–Performed Echocardiography Jorge Rabat Surgery, Fremantle Hospital, Bolivar, Bolivar, Venezuela, Bolivarian Republic Of The use of ultrasound has developed over the last 50 years into an indispensable first-line test for the cardiac evaluation of symptomatic patients. Echocardiography is a very important tool in emergency department offering vital clues in early diagnosis and also very useful in assisting therapeutic procedures. The fact that echocardiography is a portable rapid, noninvasive technology which can be repeated when required makes it highly useful in emergency department. Hence all physicians managing critically ill patients should learn the skill of echocardiographic examination in a focused Echocardiography has shown to be an essential diagnostic tool in the critically ill patient’s manner. This skill adds to the clinical acumen towards a correct diagnosis and treatment. assessment. In this scenario the initial fluid therapy, such as it is recommended in the actual
Often overlooked but still clinically important is the amniotic fluid, umbilical cord and cervix. We will review the normal and abnormal states of the amniotic fluid, umbilical cord and cervix including the differential diagnosis, appropriate ways to measure and report as well as clinical implications and management.
Quantitative Imaging Biomarker Development Moderators: Paul Carson, PhD, Mark Palmeri, MD, PhD Quantitative Pressure Estimation with Subharmonics Flemming Forsberg Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, United States Objective: Our group has previously shown the subharmonic amplitude of microbubble-based ultrasound contrast agents is a good indicator of hydrostatic pressure in vitro and has developed a noninvasive pressure measurement technique, known as subharmonic-aided pressure estimation (SHAPE), based on this principle. Noninvasive SHAPE measurements may be a useful alternative to catheter-based measurements of
Ultrasonido en Intervencionismo Hep atico. Interventional Ultrasound in Liver Jorge Rabat Surgery, Fremantle Hospital, Bolivar, Bolivar, Venezuela, Bolivarian Republic Of
Moderator: Urike Hamper, MD, MBA In the United States, ultrasound contrast agents are approved only for cardiac use. This session will review the WFUMB guidelines and explain how we in the United States can incorporate contrast-enhanced ultrasound (CEUS) into daily practice. The value of CEUS as an everyday problem-solving tool, especially for liver and genitourinary imaging, will be discussed.
El Ultrasonido se ha convertido en una herramienta diagn ostica imprescindible en la medicina del siglo XXI y ademas una alternativa de primera lınea para orientar procedimientos diagn osticos y terapeuticos. Presenta importantes ventajas como guıa de procedimientos: es barata, disponible, m ovil, no utiliza radiaciones ionizantes y requiere menos tiempo que otras tecnicas. El metodo puede realizarse usando dispositivos adaptados a las sondas o mediante la tecnica de manos libres (sosteniendo la aguja con una mano y la sonda con la otra). La realizaci on de procedimientos guiados por ecografıa requiere una planificaci on previa cuidadosa, tener una hemostasia suficiente o que la zona de punci on sea directamente compresible, obtener el consentimiento informado del paciente, y medidas de asepsia y anestesia apropiadas. Una serie de organos son susceptibles a esta tecnica, dentro de los mas comunes esta el hıgado. La tecnica de los procedimientos supone introducir la aguja o el cateter a traves del plano de corte del ec ografo. El avance se controla en tiempo real, pudiendo dirigir la aguja hasta la zona blanco seleccionado. Los procedimientos mas habituales incluyen citologıas, biopsias, drenajes e inyecciones percutaneas y aplicaci on de Radiocirugıa.. El drenaje supone casi siempre colocar un cateter en una colecci on. Puede hacerse usando las tecnicas de Seldinger, tr ocar o mediante cateteres diversos. Las complicaciones son muy pocas e incluyen sangrado, infecci on, lesiones de vıscera hueca, etc. Un Capıtulo aparte es el Ultrasonido Endosc opico Intervencionista.
Ultrasonido General (In Spanish) Moderator: Tulio Augusto Alves Macedo, MD Elastografıa Hepatica Leandro Fernandez Laboratorio de Ecografia Avanzada, Caracas, VENEZUELA, BOLIVARIAN REPUBLIC OF La palpacion para estimar la dureza de una lesi on era un metodo de diagn ostico practicado en Egipto en 2600 AC y la Elastografıa ofrece una ‘‘palpacion virtual’’. Esta tecnica proporciona una representacion visual de la informacion tactil obtenida por palpacion fısica del tejido. Basado en el trabajo de Ophir et al, la industria comenzo a desarrollar los instrumentos adecuado para hacer este tipo de estudio es posible. Al mismo tiempo, los investigadores clınicos comenzaron a validar los resultados obtenidos mediante el uso de este proceso. La imagen es el resultado de la comparacion matematica entre la rigidez de la lesion rodeada por tejido normal. Para una mejor comprension, debemos definir algunos terminos; Elasticidad: capacidad de un objeto para deformarse bajo presion. Rigidez: incapacidad para deformarse bajo presion. Tension: cantidad de deformacion del tejido. Fuente de Compresion: es la forma c omo se ejerce la fuerza para comprimir el tejido Hay diferentes tipos de Elastografıa, que han sido utilizadas en el tiempo: Transitoria, Tension en Tiempo Real y Cuantitativa como ARFI y Shear Wave. Para la evaluacion de fibrosis hepatica y neoplasias, estas ultimas han demostrado tener mejores resultados. Las tecnicas cuantitativas ofrecen valores especıficos que mejoran la reproductibilidad del metodo. Sus valores se expresan en metros/segundo o kilopascales. El metodo es altamente efectivo y de acuerdo a sus resultados puede decidirse en la mayorıa de los pacientes si es necesaria o no, la realizacion de biopsia hepatica. __________________________________________________ ____ Sporea Ioan. Hepatic Elastography Using Ultrasound Waves. DOI 10.2174/97816080546331120101. eISBN: 978-160805-463-3 Ferraioli G et al. Accuracy of Real-Time Shear Wave Elastography for Assessing Liver Fibrosis in Chronic Hepatitis C: A Pilot Study. Hepatology. Vol. 56(6): 2125-33. 2012
Lesiones Hepaticas Focales Malignas Maria Cristina Chammas Radiology, University of Sao Paulo, Sao Paulo, Sao Paulo, Brazil LEARNING OBJECTIVES To discuss the basics of ultrasound diagnosis of malignant focal liver lesions (FLL). To present the main standards of FLL on B-mode US and the vascular patterns of lesions (Doppler US and CEUS). How to describe the malignant FLL. To learn about the potential value as well as the limitations of Contrast Enhanced Ultrasound (CEUS) in FLL. The diagnosis of malignant focal liver lesions is based on the association of clinical findings and ultrasound findings (both B-mode and in the vascularization pattern of these lesions). The main questions to be answered are: this finding is incidental in a healthy patient or the focal lesion is part of a broader framework Regarding to clinical features, the main issues are: the injury is incidental in a healthy patient or the FLL is part of the one clinical presentation, as monitoring cancer treatment, infectious or if the patient has a chronic liver disease, in follow up of hepatocellular carcinoma (HCC). What symptoms are present: fever, consuptivo context, etc. Concerning previous treatments: must also be searched. Presentation of typical pattern and enhancement patterns of various histologic types of malignant FLL on B-mode and Contrast Enhanced
S44
Abstracts
S45
Ultrasound (CEUS), respectively. Explanation of their hemodynamic behaviour post contrast injection based on their histology and recognition of atypical patterns of contrast enhancement. The main malignant FLLs will be presented (cases of the HCC and metastases). Since the FLL is present, how to describe the main findings of the lesions is essential. FLL should be characterized as the location (segment), number of lesions( if 3 or more nodules), size (at least 2 axes), echotexture, echogenicity, presence of necrosis / calcification / perinodular halo. Margin: regularity / definition. Besides these findigns, it is very important characterize if there is vascular infiltration / thrombosis (portal vein, hepatic veins, ICV). If there is thrombosis of the portal system: staging it is helpful (give affected segments, extension). Another point is trying to define the thrombosis origin (hematogenous or tumoral). Presence of dilatation of the bile ducts must be reported, and ascites as well. The pattern of liver parenchyma must be reported: chronic liver disease or not / volume redistribution and other signs of cirrhosis.
clinical guidelines, not always provides the desired results and maintains a considerable incidence of cardiorespiratory insufficiency. Echocardiography can council us on these patients’ clinical handling, not only the initial fluid therapy but also on the best-suited election of the vasoactive/inotropic treatment and the early detection of complications. It contributes as well to improving the etiological diagnosis, allowing one to know the heart performance with more precision. The parameters that are evaluated cardiac function, ejection fraction, and Cardiac Output index, systolic volume. The Pre-load: Ventricular size, diameter of the inferior vena cava (IVC). Post-load: Peripheral Vascular Resistance Anatomy: pericardial fluid with or without tamponade. Probably is the time that hemodinamic monitoring guided by Ultrasound be generalized in all ICUs
Hands-on Scanning: Peripheral Nerves of the Upper Extremity
Concomitant Entities During Gestation: Is There a Mole Among Us? Margaret Dziadosz New York University, New York, New Jersey, United States
Moderators: Kenneth Lee, MD, Humberto Rosas, MD On completion of this session, participants will have gained hands-on experience in scanning the periperal nerves of the upper extremity.
Nonfetal Obstetric Ultrasound Moderator: Ana Monteagudo, MD
Moderators: Dean Nakamoto, MD, Cornnie Deurdulian, MD
It is estimated that 1/22,000 – 1/100,000 gestations will have a concomitant molar gestation present. Increased first trimester surveillance allows further diagnosis but also opens a pandoras box of differential diagnosis including that of subchorionic hematoma and placental mesencymal dysplasia. Definitive diagnosis has significant implications for patient counseling and potential for morbid outcomes. Normal sonographic placental appearance, concomitant molar gestations and sonographic differentials will be presented in addition to a brief commentary on clinical significance of abnormal findings.
After attending this session, participants will be able to identify some common as well as uncommon complications during interventional procedures. They will also understand how to avoid possible complications and ways to manage them once the complications do occur.
Beyond the placenta: Amniotic fluid, umbilical cord and cervix Jonathan Rosner OB/GYN, Division of MFM, NYU Langone Medical Center , New York, New York, United States
Know When to Hold ’Em: How to Avoid Complications During Interventional Procedures and How to Manage When You Get Them
New Horizons in Critical Care: Part 1 Moderator: Eitan Dickman, MD, RDMS Update in Clinician–Performed Echocardiography Jorge Rabat Surgery, Fremantle Hospital, Bolivar, Bolivar, Venezuela, Bolivarian Republic Of The use of ultrasound has developed over the last 50 years into an indispensable first-line test for the cardiac evaluation of symptomatic patients. Echocardiography is a very important tool in emergency department offering vital clues in early diagnosis and also very useful in assisting therapeutic procedures. The fact that echocardiography is a portable rapid, noninvasive technology which can be repeated when required makes it highly useful in emergency department. Hence all physicians managing critically ill patients should learn the skill of echocardiographic examination in a focused Echocardiography has shown to be an essential diagnostic tool in the critically ill patient’s manner. This skill adds to the clinical acumen towards a correct diagnosis and treatment. assessment. In this scenario the initial fluid therapy, such as it is recommended in the actual
Often overlooked but still clinically important is the amniotic fluid, umbilical cord and cervix. We will review the normal and abnormal states of the amniotic fluid, umbilical cord and cervix including the differential diagnosis, appropriate ways to measure and report as well as clinical implications and management.
Quantitative Imaging Biomarker Development Moderators: Paul Carson, PhD, Mark Palmeri, MD, PhD Quantitative Pressure Estimation with Subharmonics Flemming Forsberg Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, United States Objective: Our group has previously shown the subharmonic amplitude of microbubble-based ultrasound contrast agents is a good indicator of hydrostatic pressure in vitro and has developed a noninvasive pressure measurement technique, known as subharmonic-aided pressure estimation (SHAPE), based on this principle. Noninvasive SHAPE measurements may be a useful alternative to catheter-based measurements of