Purpose: The coracohumeral ligament (CHL) complex plays a crucial role in the shoulder's structure and function. This study focuses on CHL pathology in cases initially presented with shoulder pain and disability. We examine the outcomes of ultrasound-guided interventions in managing this condition, along with a review of existing literature on the anatomy of shoulder and treatment of tendinopathy. Materials and Methods: We retrospectively reviewed the ultrasound studies of 17 patients diagnosed with CHL pathology and associated shoulder pain. All patients received ultrasound-guided interventions, including prolotherapy and platelet-rich plasma injection. The pretreatment and first posttreatment symptoms were reviewed and analyzed according to visual analog scale (VAS) scores. Results: The etiology of CHL pathology in our case series included traumatic injury and tendinosis. Of the 17 patients, the mean pretreatment VAS score was 6.8/10, and the mean posttreatment VAS score was 3.5/10. In total, 10 (58.8%) patients reported >50% improvement after a single treatment session. Conclusion: CHL pathology should be recognized and considered in the diagnosis of shoulder pain. Ultrasound examination is a safe and effective means of obtaining a precise diagnosis and can be used for the treatment of CHL pathology.

Abstract Objective Ultrasound shear wave elastography is an objective tool to evaluate the stiffness of human tissues. Patients with sialolithiasis could be treated by interventional sialendoscopy with a high success rate. Sialolithiasis could be extracted, and the diseased gland could be preserved and evaluated after treatment. Whether ultrasound shear wave elastography could be used for objective outcome measurement and short‐term follow‐up of the parenchyma of gland in patients with sialolithiasis remains unclear. Methods This retrospective self‐controlled study was conducted. Patients with sialolithiasis treated by interventional sialendoscopy and followed by high‐resolution ultrasound shear wave elastography were selected between January and September 2017. Results Seventeen patients with sialolithiasis (mean age: 39.63 ± 12.49 years), including 10 women and 7 men, were enrolled. Fifteen patients had sialolithiasis in the submandibular gland and two in the parotid gland. The preoperative value of shear wave velocity was significantly higher in the diseased gland than in the contralateral normal gland (p < .001; 95% confidence interval [CI], 0.3915–0.6046). After successful treatment by interventional sialendoscopy surgery, the shear wave velocity of the diseased gland decreased significantly (p = 0.001; 95% CI, −0.38792 to −0.20474). However, there was a significant difference between the diseased and contralateral normal glands (p = 0.001; 95% CI, 0.0423–0.2895) after 1.55 months of surgery. Conclusion Ultrasound shear wave elastography could be an adjuvant tool to distinguish sialolithiasis‐affected diseased glands from contralateral normal glands and assess the short‐term treatment outcome objectively. The changing trend of shear wave velocity could help monitor the healing process of the parenchyma in the diseased gland after treatment. Level of Evidence 4

Lymphangiography and Contrast-Enhanced Lymphosonography for the Diagnosis of ChyluriaHsien-Tzu Liu, MD1,2 and Hsin-Kai Wang, MD1,2Audio Available | Share

Introduction Persistent lymphatic leakage from the surgical drain is a troubling complication occasionally encountered postoperatively. This study investigated lymphatic leaks after renal or liver transplantation, comparing the treatment efficacy of traditional catheter drainage vs. minimally invasive lymphatic interventions. We also discuss access and treatment targets considering the physiology of lymphatic flow. Methods Between September 2018 and September 2020, 13 patients with lymphatic leakage were treated with minimally invasive lymphatic interventions; 11 had received a renal transplant, and two received a liver transplant. The control group included 10 patients with postrenal transplant lymphatic leakage treated with catheter drainage. The treatment efficacy of catheter drainage, lymphatic interventions, and different targets of embolization were compared. Results The technical success rate for lymphatic intervention was 100%, and the clinical success rate was 92%, with an 82.9% reduction in drain volume on the first day after treatment. The duration to reach clinical success was 5.9 days with lymphatic intervention, and 33.9 days with conservative catheter drainage. Conclusion Lymphangiography and embolization are minimally invasive and efficient procedures for treating persistent lymphatic leaks after renal or liver transplantation. We suggest prompt diagnosis and embolization at upstream lymphatics to reduce the duration of drain retention, days of hospitalization, and associated comorbidities.

Background. This study measures the first-pass arrival times in the hepatic artery and portal vein of the transplanted liver using contrast-enhanced ultrasound (CEUS) and assess its correla-tion with graft performance in the early posttransplant period. Methods. This study evaluated 35 liver transplant recipients who underwent CEUS examina-tion within 1 month of transplant surgery. CEUS under contrast-specific harmonic imaging mode were recorded for 60 seconds immediately after intravenous administration of microbubble ultrasound contrast medium (Sonazoid, GE Healthcare, Oslo, Norway). The recorded video clips were reviewed by 2 readers to determine the first-pass arrival times in the hepatic artery and por-tal vein, and the difference between the 2 was defined as the arterial-portal arrival interval (APAI). Laboratory data on the same date of CEUS examination were collected as indicators to correlate with APAI. Results. The intra-and inter-rater reliability for APAI measurement were excellent, with intra-class correlation coefficients > .95. The mean APAI was 4.5 +/- 1.8 seconds (range, 2.0-10.5 sec -onds). The APAI was positively correlated with the serum total bilirubin level (r = 0.357, P = .035) and negatively correlated with the platelet count (r = -0.354, P = .037). At the 5 second cutoff point, a total serum bilirubin of >8 mg/dL was reported in 5 of 11 patients (45.4%) with APAI of >5 seconds and in only 3 of 24 patients (12.5%) with APAI of <5 seconds (P < .05). Conclusions. The APAI is a quantitative marker that links the hemodynamics and the clinical status of the liver graft.

To evaluate the performance of the Prostate Health Index (PHI) in magnetic resonance imaging-transrectal ultrasound (MRI-TRUS) fusion prostate biopsy for the detection of clinically significant prostate cancer (csPCa). We prospectively enrolled 164 patients with at least one Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) ≥ 3 lesions who underwent MRI-TRUS fusion prostate biopsy. Of the PSA-derived biomarkers, the PHI had the best performance in predicting csPCa (AUC 0.792, CI 0.707–0.877) in patients with PI-RADS 4/5 lesions. Furthermore, the predictive power of PHI was even higher in the patients with PI-RADS 3 lesions (AUC 0.884, CI 0.792–0.976). To minimize missing csPCa, we used a PHI cutoff of 27 and 7.4% of patients with PI-RADS 4/5 lesions could have avoided a biopsy. At this level, 2.0% of cases with csPCa would have been missed, with sensitivity and NPV rates of 98.0% and 87.5%, respectively. However, the subgroup of PI-RADS 3 was too small to define the optimal PHI cutoff. PHI was the best PSA-derived biomarker to predict csPCa in MRI-TRUS fusion prostate biopsies in men with PI-RADS ≥ 3 lesions, especially for the patients with PI-RADS 3 lesions who gained the most value.

The accuracy in diagnosing prostate cancer (PCa) has increased with the development of multiparametric magnetic resonance imaging (mpMRI). Biparametric magnetic resonance imaging (bpMRI) was found to have a diagnostic accuracy comparable to mpMRI in detecting PCa. However, prostate MRI assessment relies on human experts and specialized training with considerable inter-reader variability. Deep learning may be a more robust approach for prostate MRI assessment. Here we present a method for autosegmenting the prostate zone and cancer region by using SegNet, a deep convolution neural network (DCNN) model. We used PROSTATEx dataset to train the model and combined different sequences into three channels of a single image. For each subject, all slices that contained the transition zone (TZ), peripheral zone (PZ), and PCa region were selected. The datasets were produced using different combinations of images, including T2-weighted (T2W) images, diffusion-weighted images (DWI) and apparent diffusion coefficient (ADC) images. Among these groups, the T2W + DWI + ADC images exhibited the best performance with a dice similarity coefficient of 90.45% for the TZ, 70.04% for the PZ, and 52.73% for the PCa region. Image sequence analysis with a DCNN model has the potential to assist PCa diagnosis.

thE dEvElopmEnt of tArgEtEd Biopsy And imAging fusion for thE prostAtE CAnCEr Systematic biopsy of the prostate using transrectal ultrasound (TRUS) is the traditional diagnostic method for prostate cancer. This standard practice has undergone significant changes in recent years with the rise and popularity of magnetic resonance imaging (MRI). Multiparametric MRI combines image information of T2-weighted images, diffusion-weighted images, and dynamic contrast-enhanced images, and is effective in detecting and localizing prostate cancer.[1] Hence, the targeted biopsy of the lesion detected by MRI has become a clinical demand to acquire a pathological diagnosis and guide further management. However, as opposed to systematic biopsy, targeted biopsy requires additional equipment support to achieve lesion targeting. Among all available methods, in-bore MRI-guided biopsy provides the most straightforward solution, in which the single imaging modality (MRI) is utilized for both lesion detection and guidance for targeted biopsy. However, the procedure is complicated and requires MR-compatible facilities. There are limited medical systems that can provide enough capacity to perform in-bore MRI-guided biopsy for all patients with lesions identified by prostate MRI. Alternatively, targeted biopsy using TRUS, as in systematic biopsy, involves an operator reviewing the MRI in advance and localizing the corresponding lesions in the TRUS image for targeted biopsy, known as cognitive TRUS-targeted biopsy. This method can be accomplished by employing the existing devices applied in TRUS-guided prostate biopsy. However, the operator requires a skilled anatomical perception to achieve accurate positioning. Besides, a substantial number of the lesions identified in MRI are not demonstrated on ultrasound images. Therefore, difficulty in lesion localization in TRUS images may be encountered with the accuracy of lesions targeting greatly dependent on the experience of the operator. The imaging fusion technology is the key solution to overcome the limitations of in-bore MRI-guided biopsy and cognitive TRUS-guided biopsy. Imaging fusion is a mature technology in the ultrasound-guided interventional procedure of the liver and has gradually been applied to guide prostate biopsy in recent years. This specific method employs an electromagnetic sensor to detect the position and scanning plane of the ultrasound transducer, and timely reconstruct the MR image equivalent to the sectional plane of TRUS. The TRUS image and reconstructed MR image are simultaneously displayed side by side or overlay to assist lesion positioning for targeted biopsy [Figure 1].

Background: Due to the lack of an evidence-based consensus, managing refractory myofascial pain syndrome is challenging for clinicians. Dextrose injection (dextrose prolotherapy) emerged as a promising, cost-effective treatment. This study evaluated the efficacy of targeted ultrasound-guided dextrose injection for localized myofascial pain syndrome. Methods: We retrospectively reviewed the clinical outcomes of 45 patients with myofascial pain syndrome refractory to alternative treatments with targeted ultrasound-guided dextrose injection. Pretreatment symptom severity and symptomatic response 1 month after treatment were statistically analyzed using a visual analog scale (VAS)-based scoring system. Results: Of 45 patients, 8 (24.4%) reported complete resolution of symptoms at the treated site. In total, 36 (80.0%) patients reported greater than 50% improvement in their symptoms. The mean pretreatment and posttreatment VAS scores were 7.0 and 2.44 (p < 0.001), indicating an overall 65.0% reduction in symptom severity. Conclusion: Targeted ultrasound-guided dextrose injection was remarkably effective for refractory localized myofascial pain syndrome, significantly reducing symptom intensities in the majority of treated patients within 1 month after a single injection.

Abstract Background In recent years, incidence and prevalence of thyroid and extrathyroid lesion is increasing in the worldwide due to increase awareness of medical check-up, and widespread use of imaging techniques. A Killian Jamieson diverticulum (KJD), a rare type of hypopharyngeal pulsion diverticulum outpouching from the lateral wall of the proximal cervical esophagus, was incidentally detected and likely to be misinterpreted as a thyroid nodule while performing thyroid sonography. Clearly differentiate between those lesions is essential to avoid unnecessary invasive procedure. Here we report a typical case of bilateral Killian Jamieson diverticulum mimicking thyroid nodules. Clinical case A 57-year-old Taiwanese man was referred to our endocrine outpatient department for further evaluation of thyroid nodules. The lesions were discovered while sonographic examination performed in the clinic for routine medical check-up. He denied having dysphagia, epigastric pain, odynophagia, halitosis, chronic cough or acid regurgitation, body weight loss, fever and dyspnea. He had no previous systemic disease and no prior radiation therapy. He lives in Nangang District, Taipei city. His body weight was 70 kg and BMI was 25. An examination of head and neck was unremarkable. Laboratory data revealed normal thyroid function (TSH: 0.67 uIU/ml; range 0.4~4.0, free T4: 0.83 ng/dl; range 0.9~1.8 and aTPO <1.0 IU/ml; range <5). Thyroid ultrasonography demonstrated oval, hypoechoic nodule-like lesions containing bright foci with acoustic shadow in the posterior aspect of the both lobes of thyroid gland. The rest of thyroid glands were normal appearance. An esophagography was performed and showed two contrast-filling anterior outpouching lesions at both sides of the cervical esophagus, around C7 level and both lesions were showing anterior outpouching appearance, consider Killian-Jamieson diverticulum. Taken together, he was diagnosed as KJD and clinical follow-up alone is suggested. Clinical lessons KJD is usually incidentally detected and misdiagnosed as a thyroid nodule containing punctuate microcalcification foci as found in papillary thyroid carcinoma. To differentiate these nodules, real time sonographic examination is important. Although rare, non-thyroid lesions originating from the esophagus should be considered in the differential diagnosis of the thyroid nodules to avoid unnecessary invasive fine needle aspiration of thyroid gland.

Although examination of the spleen is routinely included in the general abdominal gray-scale ultrasound (US) study, it was considered of limited use in the past and was performed almost only to distinguish between cystic and solid lesions. In the last two decades due to accumulated experience and the introduction of second-generation contrast agents, this technique has been re-evaluated as contrast-enhanced US (CEUS) allows detection and characterization of most focal lesions of the spleen with a high sensitivity and a good specificity. US can provide a correct diagnosis in simple cysts, whereas CEUS is useful when cystic lymphangioma is suspected. US presents a low specificity and relatively low sensitivity in splenic infarctions, while CEUS can achieve a high specificity (up to 100 %). There is a wide spectrum of benign and malignant neoplasms of the spleen. Lymphomas and vascular tumors comprise the most common splenic neoplasms. Splenic hemangiomas and angiosarcomas are the most common mesenchymal tumors in which US and CEUS may show characteristic imaging findings and permit precise diagnosis. US-guided fine needle aspiration and/or biopsy of focal splenic lesions are being increasingly performed to obtain tissue for histopathological characterization. Accurate diagnosis of focal splenic lesions allows institution of optimal patient management. In the study of splenic lesions, the most important problem is to differentiate between angioma, hamartoma, lymphoma, and metastasis. CEUS presents a high specificity in the differentiation of benign and malignant splenic lesions, as hypoenhancement in the parenchymal phase is suggestive of malignancy in 87 % of cases. US, as compared to CT and MRI, has certain advantages, including its ubiquitous availability, lack of ionizing radiation, and low cost, and with additional application of CEUS, can be widely indicated in the study of focal splenic lesions.

Background: The purpose of this study was to report the safety of perfluorobutane (Sonazoid) as a vascular-phase imaging agent in characterizing focal liver lesions (FLLs). Materials and Methods: From May 2014 to April 2015, a total of 54 individuals who received Sonazoid contrast-enhanced ultrasound (CEUS) were enrolled at 5 hospitals of 4 medical centers. All individuals were included in safety evaluation. A prospective study to evaluate the adverse effect (AE) incidences after intravenous administration of Sonazoid. Results: Sonazoid was well tolerated. Treatment-emergent adverse events (TEAEs) representing AE were recorded for 13 (24.1%) patients. The most common AE was abdominal pain (9.3%), followed by heart rate irregularity (5.6%). The majority of these patients (69.2%) experienced TEAEs that were mild in intensity. Sonazoid causes no significant AEs after intravenous injection. The only noteworthy AEs are related to tolerable myalgia (3.7%), abdominal pain (1.9%), and headache (1.9%). None of the 54 patients showed serious adverse effects. Conclusion: Sonazoid shows good safety and tolerance of intravenous use during CEUS of the liver for evaluation of FLLs.

BACKGROUND:This study evaluated the performance of histogram analysis in the time course of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) for differentiating cancerous tissues from benign tissues in the prostate.METHODS:We retrospectively analyzed the histograms of DCE-MRI of 30 patients. Histograms within regions of interest(ROI) in the peripheral zone (PZ) and transitional zone (TZ) were separately analyzed. The maximum difference wash-in slope (MWS) and delay phase slope (DPS) were defined for each voxel. Differences in histogram parameters, namely the mean, standard deviation (SD), the coefficient of variation (CV), kurtosis, skewness, interquartile range (IQR), percentile (P10, P25, P75, P90, and P90P10), Range, and modified full width at half-maximum (mFWHM) between cancerous and benign tissues were assessed.RESULTS:In the TZ, CV for ROIs of 7.5 and 10mm was the only significantly different parameter of the MWS (P = 0.034 and P = 0.004, respectively), whereas many parameters of the DPS (mean, skewness, P10, P25, P50, P75 and P90) differed significantly (P = <0.001-0.016 and area under the curve [AUC] = 0.73-0.822). In the PZ, all parameters of the MWS exhibited significant differences, except kurtosis and skewness in the ROI of 7.5mm(P = <0.001-0.017 and AUC = 0.865-0.898). SD, IQR, mFWHM, P90P10 and Range were also significant differences in the DPS (P = 0.001-0.035).CONCLUSION:The histogram analysis of DCE-MRI is a potentially useful approach for differentiating prostate cancer from normal tissues. Different histogram parameters of the MWS and DPS should be applied in the TZ and PZ.

CT and MRI scans of human anatomical specimens into 3D-printed replicas.We're the first group in the world to use additive manufacturing (3D printing) to produce such precise replicas of human anatomy.Standard anatomical models are plastic injectionmoulded and painted copies of someone's crude perception of 'idealised' anatomy.They're all identical, simplified, and often bear little resemblance to real human anatomy.Our 3D-printed replicas, however, reproduce the detailed and complex anatomy of the human body down to an accuracy of 0.5mm, and contain features that could never be reproduced by industrial-scale injection moulding.As a consequence, our unique replicas have proven to be extremely powerful teaching tools not only at Monash University, but globally.

Background: Thyroid cancer is the most prevalent endocrine malignancy, and the incidence of thyroid cancer has increased worldwide. Fine needle aspiration (FNA) for cytology of thyroid tissue is used for differentiating thyroid cancers from benign thyroid nodules. Overuse of FNA may detect subclinical thyroid cancer and play a role in the increased incidence of thyroid cancer. The aim of this study was to evaluate trends in incidence of thyroid cancer and the use of palpation-guided FNA thyroid and ultrasound-guided FNA thyroid in Taiwan. Methods: By retrospectively analyzing a cohort dataset of one million people randomly sample to represent as NHI beneficiaries of Taiwan National Health Insurance Research Database from 2004 to 2010, patients who received palpation-guided and ultrasound-guided thyroid FNA were identified. Individuals who were diagnosed as having thyroid cancer were determined. Age-standardized, yearly rates of palpation-guided thyroid FNA and ultrasound-guided FNA, and age-standardized, yearly incidence rates of thyroid cancer were calculated. Results: In the study period, a total of 541 patients were newly diagnosed with thyroid cancer, 14,240 individuals received palpation-guided thyroid FNA, and 3823 individuals underwent ultrasound-guided thyroid FNA. There was a 94.8% increase in the age-standardized annual incidence rate of thyroid cancer. The age-standardized rates of palpation-guided thyroid FNA and ultrasound-guided thyroid FNA increased by 10.9% and 349.3%, respectively. Conclusion: FNA for cytology of thyroid tissue, especially ultrasound-guided FNA, was conducted by physicians more frequently in Taiwan. Increased use of FNA, especially ultrasound-guided FNA for cytology of thyroid tissue, may attribute to the increased incidence of thyroid cancer in Taiwan. Copyright (C) 2017, the Chinese Medical Association. Published by Elsevier Taiwan LLC.

Contrast-enhanced ultrasound (CEUS) has been used to diagnose gallbladder (GB) diseases for recent years because it is sensitive to visualize vascularity. Herein, we report a case who had a 1.7 cm × 1.2 cm polypoid lesion located in the gallbladder fundus with a feeding artery located in the stalk. On CEUS, the lesion showed early arterial phase enhancement (time to peak enhancement 18 s), persisting throughout the venous and delay phases. This enhancing pattern suggested that the lesion was a GB adenoma rather than a GB carcinoma. Cholecystectomy was performed, and pathology of the tissue revealed tubular adenoma of the GB.

Ultrasound is a frequently used diagnostic tool for gallbladder diseases. Polypoid lesions are commonly depicted at routine abdominal ultrasonography (US). The characteristics of these lesions vary. Since most early malignant tumors in the gallbladder are asymptomatic, differentiation between malignancy and benignity is crucial. Knowledge of gallbladder polypoid lesions is important so that they can be appropriately included in the differential diagnosis in patients presenting with intra-gallbladder nodules on US. This article summarizes the algorithmic approach to the diagnosis of these lesions and our recent experience with contrast-enhanced US. The clinical and imaging features of gallbladder polypoid lesions are reviewed.

Objectives Prolotherapy is an injection‐based complementary treatment for various musculoskeletal diseases. The aim of this study was to evaluate the therapeutic efficacy of ultrasound‐guided prolotherapy in the treatment of acromial enthesopathy and acromioclavicular joint arthropathy. Methods Thirty‐one patients with chronic moderate‐to‐severe shoulder pain were recruited from September 2015 to September 2017. Ultrasound‐guided prolotherapy was performed by injecting 10 mL of a 15% dextrose solution into the acromial enthesis of the deltoid or acromioclavicular joint capsule aseptically. Prolotherapy was given in 2 sessions separated by a 1‐month interval. The pretreatment‐to‐posttreatment change in the pain visual analog scale (VAS) score was recorded as the primary outcome. The mean follow‐up duration was 61.8 days. A paired t test was used to assess the difference in pretreatment and posttreatment VAS scores. A univariate logistic regression analysis was conducted to identify the demographic variables associated with substantial pain reduction after the intervention. Substantial pain reduction was defined as a posttreatment VAS score of 3 or less. Results Twenty of the 31 patients reported substantial pain reduction without adverse effects after the intervention. The mean VAS score reduction ± SD was 4.3 ± 2.6 (pretreatment, 6.8 ± 1.5; posttreatment, 2.5 ± 2.1; P < .01). Conclusions Ultrasound‐guided prolotherapy with a 15% dextrose solution is an effective and safe therapeutic option for moderate‐to‐severe acromial enthesopathy and acromioclavicular joint arthropathy.

Hepatic arterial pseudoaneurysm is a rare but potentially fatal condition that requires prompt management. We report a case of hepatic arterial pseudoaneurysm developed after radiofrequency ablation of a hepatocellular carcinoma. The patient was successfully treated with percutaneous absolute ethanol injection under ultrasound guidance. Follow‐up studies with ultrasound and computed tomography for 2 years after treatment revealed no evidence of local recurrence of hepatocellular carcinoma and of the pseudoaneurysm.