Euroson 2015 presentation inovative techniques athens

1. Södra Älvsborgs Sjukhus
Södra Älvsborgs Sjukhus
Innovative techniques for the diagnosis
and treatment of soft tissue lesions
Michael Papagiannakis
Radiology Department Södra Älvsborgs Sjukhus.
Papagiannaki Radiology-Chania Radiology
Consultants.

2. Södra Älvsborgs Sjukhus
soft tissue lesions
Benign or traumatic lesions:
cysts-ganglia, lipomas,
seromas-hematomas, fat
necrosis, hemangiomas,
fibromas, schwanomas
Malignant lesions:
Primary tumors:
Usually Pleomorphic sarcoma,
liposarcoma, leiomyosarcoma
Metastasis
Lymphomas
Soft tissue lesions are a common finding in clinical practice,
and usually present as palpable masses. [1,2,3]
1. Soudack et al, J Ultrasound Med 2006
2. DiDomenico & Middleton, Radiol Clin N Am 2014
3. Jin et al, AJR 2010
Inflammatory lesions:
septic bursitis, phlegmon,
abscess or lymph nodes

3. Södra Älvsborgs Sjukhus
Criteria suggesting malignancy :
Size > 5 cm
Margins
Rapid growth
Deep location and extending
beyond fascias
Increased color Doppler
Current diagnostic procedures
 Ultrasonography as a first approach is
usually adequate in detecting and
characterizing lesions with typical
appearance and based on several
criteria even suggest malignancy on
atypical lesions.[1,3,4]
 Next step is CEMRI or CECT
Definite diagnosis in several
cases.[3,5,8]
 FNA or Core-biopsy
A lot of failures especially in
indeterminate lesions[6]
4. Stramare et al, J Ultrasound 2013
5. De Marchi et al.,Eur Journal Rad 2015
6. Gay et al., Diagn.& Interven. Imaging 2012
7. Didolkar et al., Clin Orthop Relat Res 2013
8. Kransdorf & Murphey, AJR 2000

4. Södra Älvsborgs Sjukhus
US criteria are uncertain since
some malignant lesions are
superficial and color Doppler
cannot visualize perfusion [7,8].
Microvascularity and perfusion are
vital in distinguishing benign from
malignant lesions, and help in
monitoring treatment response
[4,5,8].
CE-CT,CE-MRI have several
contraindications like claustrophobia,
obesity, metal implants, or
compromised renal function.
Several limitations exist:
• Reduced spatial and temporal
resolution.
• Interstitial phase limits vascularity
assessment.
• Lack of universally established
protocols reduces accuracy
[5,7,8,9,10,11].
US guided biopsies are vital
but missing the most vivid or
representative area of a lesion
is often [7,9,10].
9. Manaster, AJR 2013
10.Hye Won Chung et al., Ultrasonography 2015
11.Loizides et al., Eur Radiol. 2012
12.Tagliafico et al., Eur Radiol. 2015
13.De Marchi et al., Eur Radiol. 2010
Is there room for new methods?

5. Södra Älvsborgs Sjukhus
Using Contrast Enhanced UltraSound
(CEUS):
 Depict vascularity in real time.
 Washout more obvious and
quantification is easy.
 No interstitial phase.
 Safer contrast agent [4,8,11,12].
 Intracavitary injections [13]
 Avoid necrosis during biopsies.[10]
Using Elastography:
 Lesions stiffness. Hard probably
malignant soft probably benign.
 Differentiate between solid, cystic
lesions [2,14,15].
 Elastography is mainly used on breast,
thyroid, liver, but indications are
constantly growing.
12.Piscaglia et al., Ultraschall in Med 2012
13.Cantisani & Wilson, Eur J Radiology 2015
14.Ignee et al., Scand J Gastroenterol 2015
Innovative techniques
15.EFSUMB guidelines on elastography
part 1&2, Ultraschall in Med 2013
16. Riishede I et al, Ultraschall 2015
diagnostic potentials in
various organs[11,12]
more information
compared with B-Mode

6. Södra Älvsborgs Sjukhus
 Enrich the baseline examination especially on incidental findings or
when there is an atypical B-mode image.
 Use perfusion to clearly delineate lesions.
 Increase the diagnostic value in patients with reduced renal function.
 Increase biopsy accuracy by avoiding necrosis.
 Differentiate between abscess, phlegmon and hematoma.
 Identify circulation on atypical cystic lesions.
 Extravascular usage for fistulas.
 Verify correct drain placement, identify multicompartment abscesses
So what can we do with CEUS in
real clinical practice?

7. Södra Älvsborgs Sjukhus
Suspected
aneurysm on single
phase CT
 Third aged patient with lower
abdomen symptoms, unable
to walk.
 Single phase CECT
suspected aneurysm arising
from RFA.
 B-mode US cystic ? lesion,
vessels on PD, low RI.
 CEUS solid hypervascular
lesion with fast uptake and
washout, eccentric necrosis,
clearly malignant.
 CEMRI late phase, malignant
lesion, necrosis, peripheral
uptake

8. Södra Älvsborgs Sjukhus
• In late arterial phase the lesion has
inhomogeneous contrast uptake with
necrotic areas
• Signs of malignancy according to criteria
proposed by Loizides et al,2012 & De
Marchi et al 2014

9. Södra Älvsborgs Sjukhus
Big intramuscular
lipoma
 Palpable lesion difficult to
visualize on B-mode.
 Lesion clearly hypo vascular
on CEUS compared to
deltoid muscle.

10. Södra Älvsborgs Sjukhus
Septic bursitis
of the shoulder
 Third aged patient with a big mass
surrounding the R shoulder joint but
vague clinical sings of inflammation.
 B-Mode reveal a mass with septa and
highly echogenic material.
 CEUS reveal inflammatory reaction of
the SASD bursa, verified by aspiration.

11. Södra Älvsborgs Sjukhus
US guided
biopsy assisted
with CEUS
 Lymphoma patient. Suspected
infiltration on R gluteal muscles.
 CT guided biopsy gave
insufficient material due to
necrosis

12. Södra Älvsborgs Sjukhus
Phlegmon vs Abscess
Phlegmon

13. Södra Älvsborgs Sjukhus
Abscess with fistula

14. Södra Älvsborgs Sjukhus
Abscess vs Hematoma

15. Södra Älvsborgs Sjukhus
Fistulography
using CEUS
 Amputated patient with post-
operative complications.
 The patient had 3 scars on the
thigh stump.
 Fistulas?
 Cavities near femur?
 Cocktail of Sonovue blended
with saline was injected
consecutively in the scars.
 2 out of 3 scars were
closed, no fistula.
 The first scar had a fistula
and a cavity near the bone
were the contrast
gathered.

16. Södra Älvsborgs Sjukhus
Södra Älvsborgs Sjukhus
Thank you for your attention