Salivary Glands and Thyroid - HD

Introduction

Thank you again Paul again.
Great pleasure to be here.
Also to talk about thyroid
and salivary gland application by means of CUS.

Thyroid Applications

Why Use CUS?

Firstly, we have to ask why we have to use CUS
in this kind of field.
All of us know that ultrasound is very capable
to detect even very small tiny lesions in tired.
However, how much accurate it is,
how many fin needle aspiration that is still considered
gold standard nowadays we are doing
because if one side we detect very tiny lesions
on the other side, how many fin needle aspiration we do,
how many necessary surgical treatment we ask
for this kind of patients
and then this kind of patients usually are very young.
For how many years should we follow up In this
clinical scenario we have to understand ultrasound role,
COS Elastography fine needle aspiration role.
What about ultrasound?

Ultrasound Limitations and Studies

I report to you this table from the paper from Rag Viti
in which they tried to assess the potential role
of elastography entire nole differentiation.
The background was based on the fact that ultrasound
is not too much accurate as expected.
If you see the numbers of the ra, the range of the numbers
of literature sensitivity
and specificity, the numbers are very variable
and they concluded that unfortunately,
although very sensitive, it is variably accurate.
We also reported our experience on color doppler
because at the beginning when we started
to use color doppler we were,
we had in our mind very promising result.
However, these were not cons co consistent
with the real life.
Then some odors over towards the first tried
to group together all the ultrasound features in order
to provide what is called rads.
RADS is a system
or a reporting system in which
all the different ultrasound features are put together
to try to provide a possible risk
or malignancy of these patients.
From that point, other authors
provided their classifications.
One of the most is the Korean one
provided by walk I showed you in this table
all the different features that they take in consideration
to try to provide the risk assessment.
However, still too many fin needle aspiration.
What about financial aspiration?
When we do first try
of fin needle aspiration in literature sensitivity is
reported no more than 90%, which increases to 95
after second try and then even more after third try.
But how many fin respiration should we do?
Therefore, CUS contrast SU ultrasound
appear in the market and then was used in different fields
and also in Thailand.
I showed you some experiences published in literature.
One is from Thomas Bar
paper published in European radiology.
It tried to assess the value of qualitative
and quantitative evaluation
of COS entire no differentiation.
The results were quite good
and he concluded that this kind
of examination should be considered promising.
But what about techniques
and which are the parameters that we use every day to try
to characterize those nodules
about the dosage in literature?
There is a great variability in our previous guidelines.
Still 4.8 milliliter was considered to be recommended.
Nowadays with new equipment which are more sophisticated,
more sensitive to microbubble detection, we may also reduce
demand of a contrast agent that should be followed by bolus
of saline flesh as in the other application.
Then we do real realtime evaluation
and post processing evaluation.
These may help us to allow to do qualitative
and quantitative evaluation,
which are the qualitative parameters.
Together with May Regina
and the Fabrica Giada, we are working to together to try
to provide the update of the guidelines in this field
and we reached a look at the literature to find out
all the different parameters that have been described.
So you can have the description of vascular pattern
or you may use the quantitative parameters in order to try
to achieve better results.

Examples and Quantitative Analysis

Let's see an example. This nole was characterized
as T three at fine needle aspiration, so it needs follow up
some vessel at power doppler.
Then we injected contrast agent in real time.
You could see how nicely you can depict the vascularization
during the early phase and then the maintenance
and the consistency with the surrounding parenchyma.
This is freezing imaging
and then you can also do quantitative analysis.
Again, different softwares internal or external.
At the end you can achieve different parameters
and then you can evaluate in post-processing.
If you look to other paper present in literature,
NEC confirmed good results as reported by
to ma Barta stating
that quantitative evaluation is more objective
than qualitative one.
But looking again to the literature,
some meta-analysis are appearing.
The first one that I would like to show you from you
what is important to point out?
Chinese are very active in this field because of the great
and tremendous incidents of Italian nole in their country.
They put together, they evaluate literature, they
assess seven studies, they did their meta-analysis
and they showed results which were just a bit more than
80% of sensitivity and specificity
and conclusive concluded,
confirming promising results as reported by Barolo dynamic
before, again we did look even
farther to the literature.
We included other meta-analysis, other studies.
What was clear that we may achieve
better results if we put together some parameters.
One could be in order to do the analysis of benign nole,
the dreamlike announcement
but parallelly another ultrasound technique is emerging
like ultrasound histography, some OT started to try
to understand if I compare COS
with the ultrasound histography, which kind
of results could I achieve?
3D Cruz was the first one she tested
qualitative elastography by means of strain elastography
so far compressive technique with quantitative evaluation
by means of software applied to COS evaluation
and the sensitivity was better by using
elastography than CUS.
If you look at another paper published by Giusti
in which they analyze it, T three
T three means indeterminate nodules.
So the ones that are more worrisome to be malignant
but are not conclusive at fine needle aspiration.
And they also concluded that elastography
would provide better results than COS,
especially if combined with ultrasound in order to
classify those nodules.
Also our group did a study in this field
and we presented at SNA then we published in European Journal radiology.
We studied 88 patients
after injection 2.4 milliliter of contrast agent.
We did qualitative analysis by means of CS
and compared with QL elastography which means strain ratio
based elastography semi quantitative one,
the results showed better sensitivity
of ultrasound histography
and quite better specificity of C os.

Case Examples for Thyroid

Let's see an example. Small nole hyper
coic with irregular halo sign,
highly vascularized color doppler
but soft at strain ratio evaluation
with a number which was less than two.
Then we injected contrast agent homogeneous announcement
and persistent announcement also during the late phase.
Other case this was a proven
malignant no, this is characterized by
multiple calcification within it
and then elastography showed
so a stiff lesion and
after the injection
or contrast agent the lesion
showed no announcement during the whole vascular phases.
Other case lesion is here,
then here is better.
The delineated and the lesion
which was at al aspiration Type three B was a benign lesion.
Histology and also quantitative software showed similar
appearance comparing with surrounding tired parenchyma

Conclusions for Thyroid

First conclusion, COS is capable
to provide micro microvascular
and may allow to us to do qualitative
and quantitative evaluation.
Malignancy findings are absence of vascularization
incomplete ring announcement,
heterogeneous announcement late a shout earlier arrival time
announcement higher and faster peak announcement.
But to now in the previous guidelines,
no recommendation was provided.
Were provided according to personal experience
but also based on updated literature reports.
We can suggest to use CUS
in the multiparametric evaluation of thyroid nodules
and also we probably, we believe
that could have a good role in order to evaluate before and
after treatment by means of RFA cry ablation
or other non-invasive treatment.

Salivary Gland Evaluation

Incidence and Tumor Types

Let's move on to salivary gland evaluation.
We know that salivary gland tumors rep represent an
incidence of one to five cases
per 100,000 people per year.
They represent two to 6% of the neoplasm.
The head and neck OT gland is the most frequently
affected gland risk factors are largely unknown
and usually multifactorial.
We may describe benign from malignant tumor
and we will describe singularly some of them
polymorphic adenoma is up to 2070 5%
of all TIC tumors as a slightly female prevalence
usually occur in fifth decade
and 5% of them may undergo to malign transformation.
Wharton tumor also called papillary cystadenoma.
Informat is up to 10% of our tumors
with male prevalence mostly occurring in 60
sometimes bilateral
and multicentric carcinoma may represent up
to 10% of all paric tumors
and they may appear throughout or adult age.
Most commonly in middle age
the most common type is dermoid carcinoma.

Study Methods

How do we study this kind of patients
by means of linear probe with low mi
one vial sono view, second generation contrast agent
or fractionated body.
Some odors especially in order to evaluate gram disease
also suggests to do introduct injection.
We recently published
and updated the review of the literature
and we tried to provide
all the features described in literature
looking at qualitative evaluation.
When you look when you deal with the malignant lesion,
you may achieve chaotic vessel formation
with increasement announcement with CS strong
but organized vessel formation with slight announcement
and wash out polymorphic adenomas shows light vessel
identification with poor perfusion
while working tumors is characterized by strong announcement
with very late washout by means
of quantitative features.
You can achieve ary under carve
and mean transit time values which are higher in malignant
compared with benign.
Also to be pointed out in working tumor
you may detect intratumoral attempt to peak
that is marked longer.
Therefore we summarize it strong criteria putting together
COS ultrasound elastography
and compared with MRI nowadays ultrasound could be
considered first line examination.
You have different weapons, use all of them according
to your availability and to your experience
and then when deletion is unconscious
you may do MRI and then needle aspiration.

Examples of Salivary Gland Lesions

Let's move on to evaluate single different
lesions such as polymorphic adenoma.
At baseline ultrasound it appears hyper coic well-defined
ate lesions with posterior acoustic announcement
At color Doran us
you do not detect strong announcement.
Sometimes if they are longstanding
and big they may appear heterogeneous
with cystic degeneration.
I will not go through MRI appearance
because it is out of the intent
and the purpose of this lecture,
but I will show you this case.
Big lesion hypo coic, some acoustic posterior enhancement,
some vessel power doppler
and then we injected the contrast agent
and you see some vessel within the lesion
but not strong announcement.
And again, just to reveal
this tiny vessel within the lesion MRI confirmed diasis
with typical feature other lesion smaller
and you see that CUS may achieve better results
to detect vascularization of dis lesion.
That is still not too much vascularized.
What about Wharton tumor?
Wharton usually appear is rounded
lobulated hypo coic masses with rich vascularization
sometimes may show internal cystic areas
and also cystic degeneration may be possible
and in this case it is not easy to discriminate
waring from polymorphic adenoma.
But let's see an example.
This hypo coic mildly heterogeneous solution over shaped.
We did power then superb microvascular imaging evaluation
that showed already that the lesion was highly vascularized.
But then we injected contrast agent
and you see how nicely
and markedly and then homogeneously the lesion is
vascularized again to prove it
and to be more objective
and to evaluate in the follow up these kind
of lesions you can use quantitative perfusion technique
and again MRI confirmed those parameters
and the ansis.
What about him and jma?
Heman, JMA and lipoma are the two lesions that when you deal
with you do the ansis directly with ultrasound
but you may achieve better results especially in pictor
evaluation by using CUS,
this hypo coic OSHA lesion
which showed also FLA light.
Then we injected contrast agent time is going on
and the vascularization started
with typical global peripheral progressive enhancement
and the lesion at at the end
of the examination was completely fulfilled by
by contrast agent.
Again, you may achieve better
and objective results by using
quantitative time intensive quantitative analysis.
And again the confirmation that was pro pro provided by MRI.
What about malignant conditions?
Usually they may have depending on the grade
of differentiation, different appearance,
but when they are typical they appear fairly marginated,
hyper coic infiltrative
with possibly some lymphoadenopathy around.
And what about the vascularization color?
Doper showed some vessel within the lesion,
but if you inject contrast agent, you see
how it heterogeneous is the vascularization but intense
and then how much faster is the washout?
And again, the confirmation at MRI

Conclusions for Salivary Glands

coming to the conclusion
ultrasound and MRI are effective technique
to detect the lesion.
Sometimes they may not achieve
complete differentiation of a deletion,
especially when the lesions are atypical.
However, when you combine ultrasound, you put together
COS include elastography,
you may do the multi parameter evaluation.
What should be taken as tecom point
CUS shows hyper vascularization
with was out in millennial lesions.
However, taking account that working tumor
also are hypervascular,
but more homogeneously war
more is more vascular acid than polymorphic adenoma.
And this is very useful especially in the cases in which in
baseline ultrasound and sometimes also finding aspiration
you were not able to discriminate those lesions.
And I suggest also
to read soon when the it will be published this paper
that is impress in European Journal ultrasound in which we try
to do a CME paper also together with Paul in order
to provide all this information
and also to guide the reader to understand how to use
all the different ultrasound technique
to achieve better results.

Closing

And since time is always going to fast, I thank you
so much showing you also a nice
but old picture of my beautiful room.
And I thank you so much for your kind attention.