The Basic And Clinical Research Of Hemodynamics In Renal Lesions With Contrast-enhanced Ultrasonography

Part One:The basic research of hemodynamics in renal lesions with contrast-enhanced ultrasonographyChapter OneUltrasound-guided implantation of VX2 renal tumors in rabbits and its feasibility studyObjective To evaluate the feasibility of establishing VX2 renal tumor model in rabbits with Ultrasound-guided implantation and ultrasonograpy. Methods Ultrasound-guided implantation was performed in bilateral kidneys of 25 New Zealand rabbits. Ultrasonography imaging was applied to observe the growth of VX2 tumor. The occurrence and the size of renal neoplasm was observed during the follow-up examination. Results The success rate of VX2 tumor implantation in rabbits was 88.0%(22/25) after operation. The occurrence rate of VX2 tumor in rabbit kidneys was 87.5%(35/40) after operation. The average size of VX2 tumor was more than 12 mm in diameter after growing of two weeks and was easy to observe with Ultrasound. Conclusion Ultrasound-guided implantation is successful to establish bilateral VX2 renal tumor model for experimental study and feasibility study with Ultrasound.Chapter TwoHigh-frequency contrast-enhanced ultrasonography of VX2 renal tumors in rabbitsObjective To explore the value of high-frequency contrast-enhanced ultrasonography (HF-CEUS) in the vascularity and detection rate of VX2 renal tumors. Methods Ten New Zealand rabbits with implanted VX2 renal tumors were scanned by the conventional Ultrasound (US) and contrast-enhanced ultrasonography (CEUS). The VX2 renal tumors in rabbits were studied between 10 and 25days after implantation. The instrument in this experimental study was the Esaote DU6 with linear transducer. The contrast agent used was SonoVue (Bracco, Italy). Necropsies and histopathologic assessment were performed in comparing CEUS with pathology. Results The detection tumors of pathology, the conventional US and CEUS were 24,11 and 21 respectively. The least tumor detected by HF-CEUS was 5 mm. The detection rate for VX2 renal tumors were 45.8% (11/24) and 87.5%(21/24) respectively between conventional Ultrasound and HF-CEUS (P=0.006). The typical performance of VX2 renal tumors in rabbits was isochronous enhancement and delayed enhancement with CEUS. The enhancement strength of VX2 tumors was less than renal parenchyma and uneven enhancement was the mostly type. The VX2 tumors were displayed hypoechoic comparing with renal parenchyma after fast washout of contrast agent. The enhancement area on CEUS was confirmed viable tumor area by pathology, on the contrary the unenhancement area being confirmed the necrotic region. Conclusion HF-CEUS has higher sensitivity than the conventional Ultrasound in detecting blood supply and improving the detection rate of VX2 renal tumors.Part Two:The clinical research of hemodynamics in renal lesions with contrast-enhanced ultrasonographyChapter One The performance of contrast-enhanced ultrasonography in renal lesionsObjective To assess the value of contrast-enhanced ultrasonography (CEUS) in diagnosing the renal lesions. Methods Four hundred and thirty two renal lesions were scanned by conventional Ultrasound (US) and CEUS between Jun, 2004 and Feb,2010. All lesions were confirmed by operation and pathology sequentially, including 346 malignant tumors and 86 benign tumors. The size, inner echoes, boundary, blood signal and its location in tumors were observed by conventional US. The modality and phase of enhancement including the arrival time, the peak time, the washout time and enhancement appearance of lesions were investigated by CEUS. Results After CEUS, the proportion of enhanced tumors in malignant group was higher than the proportion in benign group (P=0.000). The change of enhancement phase of renal lesions was not statistically significant between malignant and benign groups(P>0.05). The isochronous enhancement was the mainly type in malignant group, on the contrary delayed enhancement being the mostly type in benign group. The change of enhancement modality was statistically significant between malignant and benign groups (P=0.000). The fast washout was the mostly type in malignant group, on the contrary isochronous or delayed washout being the mostly types in benign group. The change of washout modality was statistically significant between malignant and benign groups (P=0.000). The uneven enhancement and hyperechoic in peak time was the mostly type in malignant group, on the contrary uniform enhancement and isoechoic in peak time being the mostly type in benign group. The change of enhancement uniformity or intensity was statistically significant between malignant and benign groups respectively (P=0.000, P=0.006). In parenchymal phase,19.4%(67/346) cases were showed pseudocapsule in malignant group, on the contrary only 3.5%(3/86) cases being showed pseudocapsule in benign group. The change of display rate of pseudocapsule was statistically significant between malignant and benign groups (P=0.000)Conclusion CEUS might be useful in the diagnosis and differentiation between malignant and benign renal lesions by enhancement modality and uniformity. Chapter TwoThe comparative study of blood detection in renal lesions between conventional Ultrasound and contrast-enhanced ultrasonographyObjective To compare the display rate of blood supply in renal lesions between color Doppler flow imaging (CDFI) and CEUS. Methods Four hundred and thirty two renal lesions were scanned by CDFI and CEUS between Jun,2004 and Feb,2010. All lesions were confirmed by operation and pathology sequentially, including 346 malignant tumors and 86 benign tumors. The size, inner echoes, boundary, blood signal of tumors and its location were observed by CDFI. The degree of tumor vascularity was subjectively graded from 0 to IV. The modality and phase of enhancement, including the arrival time, the peak time, the washout time and enhancement appearance of lesions in CEUS were investigated and analyzed. Results The display rate of blood signal and arterial blood signal in malignant group were higher than the display rate in benign group respectively by CDFI. The grade III and IV were the mostly types in malignant group, as well as the grade 0 and III being the mostly types in benign group. The change of grade of tumor vascularity was statistically significant between malignant and benign groups (P=0.000). The total display rate of blood signal in renal lesions by CEUS was higher than the total display rate by CDFI, as well as display rate of blood signal in malignant group or benign group respectively (P<0.05). Conclusion CEUS has obvious advantages over CDFI in showing blood supply and improving the detection rate of blood signal.Chapter ThreeThe comparative study of uniformity detection in renal lesions between conventional Ultrasound and contrast-enhanced ultrasonographyObjective To compare the uniformity detection in renal lesions between CDFI and CEUS. Methods Four hundred and thirty two renal lesions were scanned by CDFI and CEUS between Jun,2004 and Feb,2010. All lesions were confirmed by operation and pathology sequentially, including 346 malignant tumors and 86 benign tumors. The size, inner echoes, boundary, blood signal of tumors and its location were observed by CDFI. The modality and phase of enhancement, including the arrival time, the peak time, the washout time and enhancement appearance of lesions were studied by CEUS. Renal lesions'size as determined from ultrasonography was stratified into six subgroups with a 1-cm interval. Results The proportion of solid-cystic masses in malignant group was higher than that in benign group by CDFI, but the proportion of cystic masses in malignant group lower than the proportion in benign group. The change of internal echoes of renal lesions was statistically significant between malignant and benign groups (P=0.000). In peak time,73.4%(254/346) cases were showed partly non-enhancement, uneven enhancement, septum enhancement or cellular enhancement in malignant group, on the contrary only 33.7%(29/86) cases being showed these features in benign group by CEUS. The change of uniformity detection was statistically significant between malignant and benign groups (P=0.000). The percentage of uniformity in benign group, except grade I, was higher than the percentage in malignant group by CEUS. The percentage of uniformity in malignant group was a negative correlation with tumor size (P=0.000). Conclusion CEUS is better than CDFI in fully displaying internal structure of renal lesions.Chapter FourThe value of contrast-enhanced ultrasonography in improving the diagnostic rate of small renal cell carcinomaObjective To investigate the value of CEUS in diagnosis of small renal cell carcinoma (SRCC). Methods One hundred and twenty SRCCs (≤3 cm in maximum diameter) were scanned by conventional US and CEUS between Jun, 2004 and Jan,2010. All tumors were confirmed by operation and pathology sequentially. The images, including hypoechoic tumor, hyperechoic tumor with dark-ring or intratumoral anechoic or intratumoral hypoechoic, were seen as the diagnostic criteria of SRCC by conventional US. SRCC as determined from different cortical enhancement modality was stratified into two groups by CEUS. The images, including isochronous enhancement with hyperechoic or isoechoic in peak time, delayed enhancement with hypoechoic in peak time, were seen as the diagnostic criteria of SRCC by CEUS. Results On conventional US, renal tumors were hypoechoic masses(n=21), hyperechoic tumor with dark-ring(n=14) or hyperechoic tumor with intratumoral anechoic or intratumoral hypoechoic(n=31). The positive rate of diagnosis was 5.3.3%(64/120, regarded as one tumor if the overlap) by conventional US. The change of inner echoes of SRCC in peak time was statistically significant between two groups by CEUS (P=0.000), as well as the change of performance of SRCC in parenchymal phase between two groups by CEUS (P =0.021). The change of percentage of uniformity in peak time and detection rate of pseudocapsule was not statistically between two groups by CEUS (P>0.05). Renal tumors were displayed isochronous enhancement with hyperechoic or isoechoic in peak time(n=103), delayed enhancement with hypoechoic in peak time (n=7). The positive rate of diagnosis was 91.7%(110/120) by CEUS. Conclusion The positive rate of diagnosis of SRCC by CEUS is higher than that of conventional US.Chapter FiveThe value of contrast-enhanced ultrasonography in differentiation of subtypes of renal cell carcinomaObjective To investigate the value of CEUS in differentiation of subtypes of renal cell carcinoma (RCC). Methods Three hundred and forty six RCCs were scanned by conventional US and CEUS between Jun,2004 and Feb,2010. All tumors were confirmed by operation and pathology sequentially. The size, inner echoes, boundary, blood signal of tumors and its location were observed by conventional US. The modality and phase of enhancement, including the arrival time, the peak time, the washout time and enhancement appearance of tumors were studied by CEUS. Result Renal tumors were diagnosed as clear cell renal cell carcinoma (CRCC, n=304), papillary renal cell carcinoma(PRCC, n=23) and chromophobe cell renal cell carcinoma(ChRCC, n=19) by operation and pathology. The change of performance among subtypes of RCC was not obvious by conventional US. The change of enhancement phase among subtypes of RCC was not statistically significant by CEUS (P>0.05). The change of performance in cortical phase, peak time and parenchymal phase was statistically significant between CRCC and PRCC by CEUS (P＜0.05), as well as the change of performance between CRCC and ChRCC by CEUS (P<0.05). Conclusion CEUS makes it possible to differentiate subtypes of RCC.Chapter SixThe study of contrast-enhanced ultrasonography in diagnosis of malignant and benign cystic renal lesionsObjective To investigate the value of CEUS in diagnosis of malignant and benign cystic renal lesions. Methods One hundred and three cystic renal lesions were scanned by conventional US and CEUS between Jun,2004 and Feb, 2010. All cystic tumors were confirmed by operation and pathology sequentially. Each cystic tumor, which was evaluated by wall, number of septa, calcification, intratumoral nodule, blood signal and enhancement, was categorized by using Bosniak classification system before and after CEUS. Results The change of enhancement phase was not statistically between malignant and benign groups by CEUS (P>0.05). The isochronous enhancement was the mainly type between malignant and benign groups. The isoechoic in peak time was the mostly type in benign group, but isoechoic, hyperechoic and hypoechoic in peak time being the common types in malignant group. The change of enhancement in peak time was statistically significant between malignant and benign groups (P=0.002). In peak time,1.4%(1/69) cases were showed uniform in malignant group, on the contrary 26.1%(6/23) cases being showed uniform in benign group by CEUS. The change of uniformity was statistically significant between malignant and benign groups (P =0.001). In parenchymal phase,29.0%(20/69) cases were displayed pseudocapsule in malignant group, on the contrary non-case being showed pseudocapsule in benign group. The change of pseudocapsule was statistically significant between malignant and benign groups (P=0.004). The diagnostic sensitivity, specificity, accuracy, positive predictive value, negative predictive value, positive likelihood ratio by conventional US were 55.1%(38/69),85.3%(29/34),65.0%(67/103),88.4% (38/43),48.3%(29/60),3.7 in malignant group respectively. The diagnostic sensitivity, specificity, accuracy, positive predictive value, negative predictive value, positive likelihood ratio by CEUS were 69.6%(48/69),97.1%(33/34),78.6% (81/103),98.0%(48/49),61.1%(33/54),23.7 in malignant group respectively. Conclusion CEUS is better than conventional US for cystic renal lesions in differential diagnosis of malignant and benign.Chapter SevenThe value of contrast-enhanced ultrasonography in improving the diagnostic sensitivity of renal angiomyolipomaObjective To investigate the value of CEUS in improving the diagnostic sensitivity of renal angiomyolipoma (AML). Methods Fifty two renal AMLs were scanned by conventional US and CEUS between Aug,2004 and Nov, 2009. All tumors were confirmed by operation and pathology sequentially. The size, inner echoes, boundary, blood signal of tumors and its location were observed by conventional US. Tumors as determined from hyperechoic or hypoechoic was divided into two groups. The modality and phase of enhancement in two groups, including the arrival time, the peak time, the washout time and enhancement appearance of tumors were studied by CEUS. The images, including delayed enhancement with uniform isoechoic or hyperechoic in peak time, were seen as the diagnostic criteria of AML by CEUS. Results The preoperative sensitivity of renal AML was 65.4%(34/52) by conventional US. In cortical phase, forty two cases were displayed delayed enhancement by CEUS. In peak time, forty cases were showed uniform isoechoic or hyperechoic enhancement. The change of enhancement phase was not statistically between hyperechoic and hypoechoic groups (P>0.05). The change of performance in cortical and parenchymal phase was not statistically between hyperechoic and hypoechoic groups (P= 1.000,.P=0.162), on the contrary the change of performance in peak time being statistically significant in two groups by CEUS (P=0.009). The change of uniformity in cortical time or pseudocapsule in parenchymal phase was not statistically in two groups by CEUS respectively (P=0.545, P=0.083). The diagnostic sensitivity of renal AML was 76.9%(40/52) by CEUS. Conclusion CEUS might be useful for the diagnosis in reflecting the internal structure of renal AML.Chapter EightThe study of contrast-enhanced ultrasonography in improving the detection rate of difficult renal tumorsObjective To investigate the value of CEUS in improving the detection rate of difficult renal tumors. Methods Thirty six difficult renal tumors by conventional US were scanned by CEUS between Oct,2004 and Jan,2010. All difficult tumors were confirmed by operation and pathology sequentially. The size, inner echoes, boundary, blood signal of tumors and its location were observed by conventional US. The modality and phase of enhancement, including the arrival time, the peak time, the washout time and enhancement appearance of tumors were studied by CEUS. The assessment criteria of visibility of difficult renal tumors was established and calculated before and after CEUS. Results Twenty seven renal tumors of ill-defined margin and 18 isoechoic tumors were displayed by conventional US. Intratumoral or peritumoral blood signal was observed in 19 cases, while the rest cases did not been showed any blood signal. The visibility of difficult renal tumors, including boundary, inner echoes and blood supply, was better identified after CEUS. The change of visibility of difficult renal tumors was statistically significant before and after CEUS(P<0.05). The score of visibility of difficult renal tumors after CEUS was higher than the score of visibility before CEUS (P=0.000). Conclusion CEUS is better than the conventional US in significantly improving the detection rate of difficult renal tumors.Chapter NineThe comparative study of diagnostic accuracy in renal lesions between contrast-enhanced ultrasonography and contrast-enhanced computed tomographyObjective To compare the value in diagnosis of renal tumors between CEUS and contrast-enhanced computed tomography(CECT). Methods Two hundred and eighty one renal tumors were scanned by CEUS and CECT between Mar, 2007 and Feb,2010. All renal tumors were confirmed by operation and pathology sequentially. Results The change of percentage of uneven renal tumors was not statistically between CEUS and CECT in peak time. The diagnostic sensitivity, specificity, positive predictive value, negative predictive value, accuracy by CEUS were 97.3%(218/224),70.2%(40/57),92.8%(218/235),87.0%(40/46),91.8% (258/281) in malignant group respectively. The diagnostic sensitivity, specificity, positive predictive value, negative predictive value, accuracy, by CECT were 87.9% (197/224),64.9%(37/57),90.8%(197/217),57.8%(37/64),83.3%(234/281) in malignant group respectively. Conclusion The diagnostic accuracy of CEUS is slightly better than that of CECT in renal tumors.