Lung cancer is one of the commonest malignancies worldwide and necessitates both early and personalised treatment. A key requirement is histological sampling with immunohistochemistry obtained usually from percutaneous biopsy. Conventionally thoracic biopsies are performed using CT guidance, but more recently, there has been development of physician led ultrasound biopsy for pleural lesions. Contrast-enhanced ultrasound (CEUS) has been increasingly used in interventional procedures and is able to offer benefits for thoracic biopsies including improving lesional visualisation and characterisation, targeting viable tissue and avoiding critical vascular structures as well as evaluating for the presence of post-procedural complications. This educational review aims to benefits of the role of CEUS in thoracic biopsies.
Objectives Bedside lung ultrasound has been indispensable during the coronavirus disease 2019 (COVID-19) pandemic, allowing us to rapidly assess critically unwell patients. We demonstrate the unique application of contrast-enhanced ultrasound with the aim of further understanding this disease. Methods Patient demographics were recorded alongside recent cross-sectional imaging and inflammatory markers. Ultrasound was conducted by experienced operators in a portable setting. Conventional six-point lung ultrasound method was used to evaluate B-lines, small (subpleural) consolidation and the pleura. Areas of small consolidation were targeted after intravenous administration of ultrasound contrast. Results The areas of small consolidations, a potential sign of pneumonia on B-mode lung ultrasound, usually enhance on contrast-enhanced ultrasound. Our study revealed these areas to be avascular, indicating an underlying thrombotic/infarction process. Findings were present in 100% of the patients we examined. We have also shown that the degree of infarction correlates with CT severity (r = 0.4) and inflammatory markers, and that these areas improve as patients recover. Conclusions We confirmed the theory of immune thrombus by identifying the presence of microthrombi in the lungs of 100% of our patients, despite 79% having had a recent negative CT pulmonary angiogram study. contrast-enhanced ultrasound can be utilised to add confidence to an uncertain COVID-19 diagnosis and for prognosticating and monitoring progress in confirmed COVID-19 patients. Contrast-enhanced ultrasound is clearly very different to CT, the gold standard, and while there are specific pathologies that can only be detected on CT, contrast-enhanced ultrasound has many advantages, most notability the ability to pick up microthrombi at the periphery of the lungs.
DESCRIPTIONA 55-year-old woman presented to cardiology clinic with chest heaviness, which worsened with walking and deep inspiration. The sensation of chest heaviness had lasted for about a year. Cardiac and chest auscultation were unremarkable. The patient's cardiovascular risk factors included treated hypertension. There was no family history of coronary artery disease. The patient's ECG demonstrated sinus bradycardia with no ST-segment changes and normal QRS morphology. Transthoracic echocardiography showed normal left ventricular systolic function with mild left ventricular hypertrophy and no valvular abnormality. Furthermore, stress echocardiography was negative for ischaemia at 80% of maximum heart rate. Subsequently, the patient was referred to CT cardiac angiography. The patient's calcium score was 0. Contrast angiography demonstrated that the right coronary artery (RCA) had originated from the pulmonary trunk (figures 1 and 2A). The origin of the left coronary artery was normal (figure 2B). Tortuous collaterals from the LAD to the inferior wall of the heart were noted (figure 2B). In neither the left main stem, left anterior descending artery, circumflex artery nor RCA was luminal stenosis identified. Furthermore, exercise stress echocardiography was conducted, which was negative for ischaemia. The patient's management was discussed at a joint cardiology and cardiothoracic meeting and it was decided to continue conservative treatment. However, further follow-up was advised.Coronary artery anomalies are present in up to 1% of the population and are classified into anomalies of origin, anomalies of the course and anomalies of termination.1 Ectopic origin of a coronary artery from the pulmonary trunk is part of a group of rare anomalies that carry a high risk of myocardial infarction and sudden death. Increased risk of Figure 1 Maximum intensity projection. The right coronary artery originates from the pulmonary trunk. RCA, right coronary artery.
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