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American Institute of Ultrasound in Medicine <strong>Proceedings</strong> J Ultrasound Med 32(suppl):S1–S134, 20131539659 Small Nodules Arising in Cirrhotic Liver DuringSurveillance: Possibility of Characterization AmongDysplastic Nodules, Early Hepatocellular Carcinoma,and Progressed Hepatocellular Carcinoma Using Contrast-Enhanced UltrasoundAntonio Giorgio, Giorgio Calisti, Umberto Scognamiglio,Nunzia Farella, Giorgio de Stefano, Filomena Di Martino,Valentina Giorgio D. Cotugno Hospital, Naples, ItalyObjectives—The evolution from low-grade dysplastic nodules(DNs) to hepatocellular carcinoma (HCC) is characterized by a gradualdisappearance of intranodular portal tracts and a progressive developmentof neoangiogenic unpaired arteries. Contrast-enhanced ultrasound (CEUS)is able to depict intranodular vascularity. The aim of this study was to evaluateCEUS in the characterization of DNs and HCC in liver cirrhosis.Methods—Forty-six consecutive patients with liver cirrhosisand a single hepatic nodule ≤2 cm were enrolled from February toDecember 2009. The nodule was continuously observed for 4 to 6 minutesfollowing contrast injected until the disappearing of the enhancement.We studied and recorded the arterial phase (15–30 seconds after contrastinjection), the portal phase (30–60 seconds), and the sinusoidal phase (60–240 seconds). Three patients needed a second injection of 2.4 mL ofSonoVue because of inadequate visualization of the enhancement. Weanalyzed the pattern of the enhancement of the lesion after contrast injection,and we compared the features of nodule and surrounding liverparenchyma. All patients underwent CEUS and subsequent US-guidedbiopsy of the lesion. Histologic findings and imaging interpretation ofDNs and HCC were compared.Results—Progressed HCC was identified by a homogeneouspattern of hypervascularization during the arterial phase with sensitivity of90.9% and specificity of 100%. Early HCC showed an inhomogeneousand reticular pattern and was identified with sensitivity of 85.7% andspecificity of 96.1%.Conclusions—CEUS is able to depict the vascularization patternof hepatic nodules during the arterial phase and to differentiate DNs,early HCC, and progressed HCC.1511998 Thyroscan: A Cost-Effective and Noninvasive AutomatedSystem for Thyroid Lesion Classification in 3-DimensionalContrast-Enhanced Ultrasound ImagesU. Rajendra Acharya, 1 Vinitha Sree, 2 M. Mutu Rama Krishnan,1 Filippo Molinari, 3 Roberto Garberoglio, 4 Jasjit Suri* 2,51Electronics and Computer Engineering, Ngee Ann Polytechnic,Singapore; 2 Global Biomedical Technologies, Roseville,California USA; 3Electronics and Telecommunications,Politecnico Torino, Torino, Italy; 4 Scientific Foundation MaurizianaONLUS, Torino, Italy; 5 Biomedical Engineering, IdahoState University, Pocatello, Idaho USAObjectives—Ultrasound has great potential to aid in the differentialdiagnosis of malignant and benign thyroid lesions, but the accuracyis still poor. We developed and analyzed a range of knowledge representationtechniques for characterizing the intranodular vascularization of thyroidlesions by using 3D contrast-enhanced ultrasound images.Methods—Twenty patients, 10 males (age, 53.5 ± 13.3 years;range, 22–71 years) and 10 females (age, 50.1 ± 10.8 years; range, 25–68years) with a previously confirmed diagnosis of a solitary thyroid nodulewere enrolled in this study. All subjects underwent a clinical examination,hormonal profile, and 3D contrast-enhanced ultrasound volume acquisitionafter 2.5 mL of SonoVue (Bracco, Italy) injection. The features of the3D volumes were extracted by using the discrete wavelet transform(DWT), and the texture of the nodular vascularization was measured byusing statistical and structural measurements. The 10 features were fed to3 type of classifiers: K-nearest neighbor (K-NN), probabilistic neural networks(PNN), and decision tree (DT).Results—The performance of the classifiers was comparedusing receiver operating characteristic (ROC) curves. The combination ofDWT and texture features coupled with K-NN resulted in good results,with an area under the ROC curve (AUC) of 0.987, a classification accuracyof 98.9%, sensitivity of 99.8%, and specificity of 98.1%. We proposeda novel integrated index called the thyroid malignancy index (TMI),made up of DWT and texture features, which was discriminant to diagnosebenign or malignant nodules using just 1 index.Conclusions—This integrated TMI can be employed for thediagnosis of benign and malignant nodules effectively. The advantage isthe fact that, to make a diagnosis, the physician needs to only look at thevalue of just 1 integrated index instead of checking the range of each individualfeature.Table 1. Performance of the ClassifiersAccuracy, Sensitivity, Specificity,Classifier TN FN TP FP % % % AUCK-NN 40 0 39 1 98.9 99.8 98.1 0.987PNN 40 0 38 2 97.8 99.8 96.3 0.975DT 40 0 38 2 97.8 99.8 96.3 0.975FN indicates false-negative; FP, false-positive; TN, true-negative; and TP,true-positive.1466379 Usefulness of Contrast-Enhanced Ultrasound in ClinicalPractice: The Spanish TrialCarlos Nicolau, 1 * Teresa Fontanilla, 2 Jose del Cura, 3 AntonioTalegon, 4 Xavier Serres 5 1 Radiology, Hospital Clinic,Barcelona, Spain; 2 Radiology, Hospital Universitario Puertade Hierro, Majadahonda, Madrid, Spain; 3 Radiology, Hospitalde Basurto, Bilbao, Spain; 4 Radiology, Hospital Virgen del Rocio,Seville, Spain; 5Radiology, Hospital Vall Hebro, Barcelona,SpainObjectives—The aim of this multicenter study was to evaluatecontrast-enhanced ultrasound (CEUS) diagnostic performance in clinicalpractice in Spain.Methods—A total of 1786 patients (mean age, 59.8 years) from42 hospitals, with baseline US studies that were considered inconclusive,were included in this multicenter study. We evaluated 1516 (84.9%) abdominalcases (including 1272 livers [71.2%], 179 kidneys [10%], 35spleens [2%], 17 pancreases [1%], and 38 in other abdominal locations[2.1%]), 77 breast studies (4.3%), 111 supra-aortic vessel studies (6.2%),and 82 in other locations (4.6%). All studies were performed using specificcontrast software and intravenous injection of SonoVue (Bracco, Italy;mean dose, 3 mL). A low mechanical index (
American Institute of Ultrasound in Medicine <strong>Proceedings</strong> J Ultrasound Med 32(suppl):S1–S134, 20131517021 Four-Dimensional Subharmonic Breast Imaging: InitialExperiencesJohn Eisenbrey, 1 * Anush Sridharan, 1,2 Daniel Merton, 1Priscilla Machado, 1 Kirk Wallace, 3 Carl Chalek, 3 Kai Thomenius,3 Flemming Forsberg 1 1 Radiology, Thomas JeffersonUniversity, Philadelphia, Pennsylvania USA; 2 Electrical andComputer Engineering, Drexel University, Philadelphia, PennsylvaniaUSA; 3 GE Global Research, Niskayuna, New YorkUSAObjectives—To describe initial experiences of using 4D contrast-enhancedsubharmonic ultrasound imaging (SHI) and harmonic ultrasoundimaging (HI) for the characterization of mammographicallyidentified breast lesions.Methods—4D SHI (transmitting 4 cycle pulses at 5.8 MHz, receivingat 2.4 MHz) was performed using a modified LOGIQ 9 ultrasoundscanner with the 4D10L probe (GE Healthcare, Milwaukee, WI). Afterproviding informed consent, 39 patients scheduled for an ultrasoundguidedbreast biopsy received 2 injections of the contrast agent Definity(Lantheus Medical Imaging, North Billerica, MA). Patients first receiveda 0.25-mL injection while being continuously scanned with 4D HI (transmitting2 cycle pulses at 5 MHz, receiving at 10 MHz). After 30 minutes,patients received a 20-µL/kg injection while undergoing 4D SHI. Boththe screen-captured, rendered images and raw slice data for the entire contrastwash-in/wash-out cycle were digitally stored for analysis and processing.Results—Volume acquisition rates varied based on the lesionsize and depth of scanning ranged from 1.7 Hz (for a 3.7 × 1.3 × 2.0-cmlesion) to 6.1 Hz (for a 6 × 4 × 6-mm lesion) with volume angles of 9° to19°. Contrast enhancement depended heavily on lesion vascularity(determined during initial physician exam using power Doppler). In 38of 39 cases, SHI resulted in better tissue suppression relative to HI andimproved contrast visualization in vascular lesions. In vascular cases, vesselconnectivity was observed in 3D space with clear visualization of contrastwash-in and wash-out. Raw slice data were successfully processed tocreate 3D maximum intensity and perfusion parametric maps. Theseprocessed volumes further improved the ability to delineate blood vesselsfrom the surrounding tissue and quantify flow parameters.Conclusions—In almost all cases, 4D SHI resulted in improvedvisualization of contrast relative to 4D HI. Access to raw slice data allowsfor the generation of 3D parametric maps of the vasculature. Future workwill determine the value of 4D SHI for characterizing breast lesions.Emergency Ultrasound, Part 1Moderators: Leslie Scoutt, MD, Gowthaman Gunabushanam, MD1540915 Accuracy of Lung Ultrasound and Chest Radiography forDiagnosis of Cardiogenic Dyspnea Among Elderly EmergencyDepartment PatientsEmanuele Pivetta, 1,2,3 * Livia Ausiello, 4 Elke Platz, 1 MichaelStone, 1 Maria Tizzani, 5 Giulio Porrino, 5 Enrico Ferreri, 5Giovanni Volpicelli, 6 Paolo Balzaretti, 4 Alessandra Banderali,7 Antonello Iacobucci, 8 Enrico Lupia, 2 Alberto Goffi, 9 GiovannaCasoli, 10 Gianalfonso Cibinel 11 1 Emergency Medicine,Division of Emergency Ultrasound, Brigham and Women’sHospital, Boston, Massachusetts USA; 2 Emergency Medicine,3Oncology and Hematology, Cancer Epidemiology Unit, SanGiovanni Battista Hospital and University of Turin, Turin, Italy;4Emergency Medicine, Mauriziano Hospital, Turin, Italy;5Emergency Medicine, San Giovanni Battista Hospital, Turin,Italy; 6 Emergency Medicine, San Luigi Gonzaga UniversityHospital, Orbassano, Turin, Italy; 7 Emergency Medicine, CardinalMassaia Hospital, Asti, Italy; 8 Emergency Medicine,Santa Croce e Carle Hospital, Cuneo, Italy; 9 Critical CareMedicine, St Michael’s Hospital, Toronto, Ontario, Canada;10Emergency Medicine, Martini Hospital, Turin, Italy; 11 EmergencyMedicine, Pinerolo Civil Hospital, Turin, ItalyObjectives—This study aimed to evaluate the diagnostic accuracyof pleural and lung ultrasound (PLUS) vs chest radiography for theidentification of interstitial syndrome and pleural effusions (indicators ofacute decompensated heart failure) among elderly patients presenting tothe emergency department (ED) with dyspnea.Methods—This was a prospective multicenter cohort study ofpatients presenting to an Italian ED with shortness of breath. After the initialassessment, emergency physicians categorized dyspnea as cardiogenicor noncardiogenic. Patients then underwent 8-zone PLUS with a curvilineartransducer assessing for sonographic artifacts (B-lines) and pleuraleffusions (mean scanning time, 3.47 minutes). Three or more B-lines weresuggestive of interstitial syndrome. The same physician then recorded thenew diagnostic category, incorporating both initial clinical assessment andPLUS findings. All patients also underwent standard chest radiography.After discharge, medical records were independently reviewed by 2 emergencyphysicians blinded to the PLUS results to determine the most likelycause of dyspnea.Results—Between October 2010 and August 2012, 674 elderlypatients were enrolled. Median age was 79 years (range, 65–99 years);54.7% were male; 22.4% had a history of heart failure; and 40.9% hadchronic obstructive pulmonary disease. In 284 subjects (42.1%) the etiologyof dyspnea was cardiogenic. PLUS had sensitivity (Se) of 97.7% (confidenceinterval [CI], 94.6%–99.2%) and specificity (Spe) of 96% (CI,93.8%–99.3%) for the diagnosis of cardiogenic dyspnea, with a positivepredictive value (PPV) of 98.1% (CI, 95.3%–99.5%) and a negative predictivevalue (NPV) of 97% (CI, 93%–99%). Chest radiography had Seof 70.3% (CI, 61.6%–78.1%), Spe of 80% (CI, 70.8%–87.3%), a PPV of81.8% (CI, 73.3%–88.5%), and an NPV of 67.8% (CI, 58.6%–76.1%).PLUS improved the clinician’s diagnostic accuracy for cardiogenic dyspneaby 10% (CI, 7.7%–12.3%).Conclusions—In our study, PLUS had higher diagnostic accuracythan chest radiography for the diagnosis of cardiogenic dyspnea inelderly ED patients. PLUS may represent a more rapid and accurate toolin the bedside assessment of patients with suspected acute decompensatedheart failure.1540969 Bedside Cardiac Ultrasound Examination to ConfirmCentral Venous Catheter PlacementYiju Liu, 1 Kathleen Calabrese, 1 * Kunal Ajmera, 2 MohammadSalimian, 1 Thaison Tran, 1 Hamid Shokoohi, 1 Keith Boniface, 1Melissa McCarthy 1 1 Emergency Medicine, George WashingtonUniversity Medical Center, Washington, DC USA;2School of Public Health and Human Services, George WashingtonUniversity, Washington, DC USAObjectives—This study evaluated the use of bedside ultrasoundexamination (BUE) to confirm proper CVC insertion. More than 5 millioncentral venous catheters (CVCs) are placed each year in the United States.Mechanical complications of CVC insertion range between 5% and 19%,and the malposition rate can be as high as 50%. Current practice of obtainingpost-CVC chest radiography (CXR) to confirm placement maydelay care and expose patients to repeated ionizing radiation.Methods—We prospectively enrolled patients requiring abovethe-diaphragmCVC placement from the emergency department (ED), intensivecare unit (ICU), and operating room (OR) at a tertiary academiccenter. Within 24 hours of CVC placement, we pushed 10 mL of saline solutionthrough a distal catheter port while simultaneously obtaining a singleview of the heart using BUE and documented whether echo signals ofthe saline solution appeared in the right heart and the timing of their appearance.We hypothesized that the immediate presence of echogenic sig-S18
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