Sonographically Guided High‐Intensity Focused Ultrasound for the Management of Uterine Fibroids

High‐intensity focused ultrasound therapy has received increasing interest in the management of solid malignancies and benign tumors. Magnetic resonance imaging has always been used to define the target for controlling and monitoring the ablation. Recently, sonographically guided high‐intensity focused ultrasound has been introduced to monitor the ablation process. This article provides an overview of the background, clinical use, and treatment outcomes of sonographically guided high‐intensity focused ultrasound in the treatment of uterine fibroids.     

Appearance of Absorbable Gelatin Compressed Sponge on Early Post‐Thyroidectomy Neck Sonography

Objective. Absorbable gelatin compressed sponge (Gelfoam; Pfizer Inc, New York, NY), a biodegradable agent prepared from purified porcine skin gelatin, is frequently used for intraoperative hemostasis. Its appearance on sonography may mimic tumor or residual thyroid when placed in the resection bed after thyroidectomy. The purpose of this study was to describe the appearance of Gelfoam on early post‐thyroidectomy sonography so that an erroneous diagnosis of locally recurrent or residual tumor can be avoided. Methods. We reviewed the early postoperative sonographic examinations of 6 patients after thyroidectomy in which Gelfoam was used for hemostasis. Screening cervical sonography was performed to identify possible lateral compartment adenopathy before completion of thyroidectomy or ablation. Sonographic examinations were performed up to 50 days after resection. Surgical reports confirmed the use of Gelfoam in each patient. Results. In all cases, uniform elongated echogenicity was shown within the lobectomy bed. In 1 patient, sonographically guided fine‐needle aspiration of lobectomy bed echogenicity yielded scant red blood cells, multinucleated giant cells, and macrophages. Follow‐up sonography performed in 1 patient 14 months after thyroidectomy confirmed complete Gelfoam absorption. Conclusions. Gelfoam may mimic residual or recurrent thyroid carcinoma on early surveillance sonography performed after thyroidectomy. Recognition of its characteristic appearance should prompt a search for an appropriate surgical history and, when placed in the appropriate clinical context, should prevent an errant diagnosis of tumor.     

Sonographic Features of Placenta Accreta After First‐Trimester Abortion

We assessed 5 patients with histologically/clinically confirmed placenta accreta after first‐trimester abortion. In 4 patients, sonography showed an unclear endometrium, absence of an endometrium‐myometrium interface, a well‐vascularized hyperechoic lesion in the uterine body with a low resistive index, and myometrial thinning near the lesion. In 2 patients, contrast‐enhanced sonography showed rapid irregular lesion enhancement. Chemotherapy reduced the lesions in 3 patients, and a decreased blood supply increased the resistive index in all lesions. Two patients each underwent hysterectomy and uterine curettage. The fifth patient had a cervical pregnancy; sonography showed a well‐vascularized hyperechoic lesion in an enlarged cervix. Methotrexate gradually reduced this lesion. Sonography, especially contrast‐enhanced sonography, can detect placenta accreta and guide treatment.     

Contrast‐Enhanced Transrectal Ultrasound for Follow‐up After Focal HIFU Ablation for Prostate Cancer

The optimal strategy for imaging after focal therapy for prostate cancer is evolving. This series is an initial report on the use of contrast‐enhanced transrectal ultrasound (TRUS) in follow‐up of patients after high‐intensity focused ultrasound (HIFU) hemiablation for prostate cancer. In 7 patients who underwent HIFU hemiablation, contrast‐enhanced TRUS findings were as follows: (1) contrast‐enhanced TRUS clearly showed the HIFU ablation defect as a sharply marginated nonenhancing zone in all patients; (2) contrast‐enhanced TRUS identified suspicious foci of recurrent enhancement within the ablation zone in 2 patients, facilitating image‐guided prostate biopsy, which showed prostate cancer; and (3) contrast‐enhanced TRUS findings correlated with multiparametric magnetic resonance imaging and biopsy histologic findings.     

Contrast‐enhanced ultrasound findings in a case of renal extramedullary hematopoiesis

We present the case of an 80‐year‐old man with two renal solid masses found at sonography, which were imaged by contrast‐enhanced ultrasound, CT, and MRI and confirmed histologically. Contrast‐enhanced ultrasound findings suggested a benign mass and a CT‐guided biopsy yielded a diagnosis of extramedullary hematopoiesis. © 2012 Wiley Periodicals, Inc. J Clin Ultrasound, 2013     

Contrast‐Enhanced Sonographic Follow‐up After Stenting of Visceral Artery Aneurysms

We report 2 cases of exclusion of visceral artery aneurysms. The first was a common hepatic artery aneurysm treated with a multilayer stent; the second was a celiac trunk aneurysm excluded by a covered stent. Computed tomographic angiography was performed at regular intervals after each procedure, together with echo color Doppler imaging and contrast‐enhanced sonography. Computed tomographic angiography and contrast‐enhanced sonography were able to detect endoleaks in both patients and the related inflow vessel; moreover, diameter measurements of the sacs were identical. In our preliminary experience, contrast‐enhanced sonography appeared to be as accurate as computed tomographic angiography after endovascular visceral artery aneurysm exclusion.     

Community‐Based Practice Experience of Unsuspected Breast Magnetic Resonance Imaging Abnormalities Evaluated With Second‐Look Sonography

Objective. The purpose of this study was to assess the utility and efficacy of second‐look breast sonography in the evaluation of abnormalities identified on presurgical breast magnetic resonance imaging (MRI) examinations. Methods. A retrospective review was performed of 152 presurgical breast MRI examinations having 196 unsuspected abnormalities to identify findings that underwent subsequent breast sonography. Eligible examinations had a suspicious abnormality identified on presurgical MRI and documentation of the location and size of the finding on MRI and subsequent second‐look sonography. Fourteen examinations not meeting the criteria were excluded, with 182 abnormalities remaining. Patient medical records were reviewed. Results. Seventy percent (128 of 182) of breast MRI lesions were visible at second‐look sonography; 30% (54 of 182) were sonographically occult. Ninety‐five percent (121 of 128) of sonographically visible abnormalities underwent breast biopsy. Pathologic examinations of sampled sonographically visible lesions revealed 39 cancers, 9 high‐risk lesions, 72 benign lesions, and 1 lesion not specified at surgery; 23% (9 of 128) of cancers were in the contralateral breast. Fifty‐four lesions were sonographically occult. Needle biopsy was performed for 93% (50 of 54) of occult lesions, revealing 8 cancers, 1 high‐risk lesion, and 41 benign lesions; 3 of the benign lesions did not have sufficient pathologic specimens but were benign at follow‐up. Magnetic resonance imaging guidance was used in 86% (43 of 50) of these biopsies. One contralateral cancer was identified in the sonographically occult subset. Of the 182 lesions that underwent second‐look sonography, 20% (36 of 182) had a change in management. Conclusions. Second‐look sonography has value in the evaluation of abnormalities found on breast MRI. We found enhancements in 70% (128 of 182), yielding 39 cancers.     

Real‐time Sonography With Electromagnetic Tracking Navigation for Biopsy of a Hepatic Neoplasm Seen Only on Arterial Phase Computed Tomography

This case illustrates the ability of electromagnetic tracking navigation to localize difficult targets in real time during biopsy or ablation of lesions that are only transiently apparent on arterial phase computed tomography and may be unapparent on sonography. Readily available technology enabling multimodality registration to sonography allows for the use of positron emission tomographic, magnetic resonance imaging, and computed tomographic information during sonographically guided procedures and examinations.     

Gelatin‐Agar Lumbosacral Spine Phantom

This report describes the preparation of a gelatin‐agar spine phantom that was used for spinal sonography and to practice the hand‐eye coordination skills required to perform sonographically guided central neuraxial blocks. The phantom was prepared by embedding a lumbosacral spine model into a mixture of gelatin and agar in a plastic box. Cellulose powder and chlorhexidine were also added to the mixture, after which it was allowed to solidify. Sonography of the osseous elements of the lumbosacral spine in the phantom was then performed, and their sonographic appearances were compared to those in volunteers. Simulated real‐time sonographically guided paramedian spinal needle insertions were also performed in the phantom. The texture and echogenicity of the phantom were subjectively comparable to those of tissue in vivo. The osseous elements of the spine in the phantom were clearly delineated, and their sonographic appearances were comparable to those seen in vivo in the volunteers. During the simulated sonographically guided spinal injections, the needle could be clearly visualized, but the phantom provided little tactile feedback. In conclusion, the gelatin‐agar spine phantom is a simple and inexpensive sonographic spine model that has a tissuelike texture and echogenicity. It can be used to study the osseous anatomy of the lumbar spine and practice the skills required to perform sonographically guided central neuraxial blocks.     

Compression‐refractory breast hematoma secondary to pseudoaneurysm after stereotactically guided vacuum‐assisted biopsy: The critical role of urgent surgical evacuation

We report the case of a patient who underwent a vacuum‐assisted biopsy of amorphous clustered microcalcifications complicated by a large compression‐refractory hematoma secondary to pseudoaneurysm formation. Breast sonography was used to identify an actively bleeding vessel and guide compression. However, due to its unresponsiveness to conventional management and rapid progression, the hematoma required surgical evacuation and ligation of the bleeding vessel. This suggests that, in the face of significant intractable bleeding, a heightened awareness of the possible need for surgical intervention should be maintained. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 42 :492–494, 2014     

Splenic trauma: evaluation with contrast-specific sonography and a second-generation contrast medium: preliminary experience.

OBJECTIVE: To report our experience in the assessment of splenic trauma with contrast-coded sonography and a second-generation contrast medium. METHODS: From January to May 2002, 120 patients were studied with sonography for suspected splenic trauma. Twenty-five were selected for further imaging because of sonographic findings positive for splenic injury, findings positive for peritoneal fluid only, indeterminate findings, and negative findings with high clinical or laboratory suspicion. These patients underwent contrast-enhanced harmonic sonography and contrast-enhanced helical computed tomography. RESULTS: Among the 25 patients studied, 6 had no spleen trauma at initial and follow-up evaluation. One patient had a hypoperfused spleen without parenchymal damage, and 18 had splenic injuries; these 19 patients were considered positive. Hemoperitoneum was identified by sonography, contrast-enhanced sonography, and contrast-enhanced computed tomography in 74% of the 19 positive cases. Perisplenic clots were recognized in 58% of the cases by computed tomography and in 42% by baseline and enhanced sonography. Splenic infarctions were found in 11% of cases by contrast-enhanced sonography and computed tomography; none was found by unenhanced sonography. Parenchymal traumatic lesions were identified in 12 of 18 patients with splenic injuries by unenhanced sonography, in 17 cases by contrast-enhanced sonography, and in all 18 cases by contrast-enhanced computed tomography. A minimal splenic lesion was found in the single patient with a false-negative contrast-enhanced sonographic finding. Contrast-enhanced sonography correlated appreciably better than unenhanced sonography in detecting injuries and in estimating their extent. Findings undetectable on unenhanced sonography were also noted: splenic hypoperfusion in 11% of positive cases on both contrast-enhanced sonography and contrast-enhanced computed tomography, contrast medium pooling in 21% of cases on both contrast-enhanced sonography and computed tomography, and contrast extravasation in 11% of cases on computed tomography and 5% on contrast-enhanced sonography. CONCLUSIONS: Contrast-enhanced sonography is a promising tool in the assessment of splenic trauma. In institutions where sonography is used as the initial procedure, this technique may increase its effectiveness.     

Contrast‐Enhanced Ultrasonography With SonoVue

Objective. We investigated the ability of contrast‐enhanced ultrasonography with SonoVue (Bracco SpA, Milan, Italy), a sulfur hexafluoride microbubble contrast agent, to reveal differences between benign and malignant focal splenic lesions. Methods. In a prospective study we investigated 35 lesions in 35 patients (24 male and 11 female; mean age ± SD, 54 ± 15 years) with focal splenic lesions detected by B‐mode ultrasonography. After intravenous injection of 1.2 to 2.4 mL of SonoVue, the spleen was examined continuously for 3 minutes using low–mechanical index ultrasonography with contrast‐specific software. The final diagnosis was established by histologic examination, computed tomography, or magnetic resonance imaging. Results. In 14 patients, the splenic lesions were malignant (metastasis, n = 6; non‐Hodgkin lymphoma, n = 6; and Hodgkin lymphoma, n = 2). In 21 patients, the focal splenic lesions were benign (ischemic lesion, n = 6; echogenic cyst, n = 5; abscess, n = 4; hemangioma, n = 3; hematoma, n = 1; hemophagocytosis syndrome, n = 1; and splenoma, n = 1. Typical findings for benign lesions were 2 arrival patterns: no contrast enhancement (neither in the early nor in the parenchymal phase; P < .05) and the beginning of contrast enhancement in the early phase followed by contrast enhancement in the parenchymal phase 60 seconds after injection. In contrast, the combination of contrast enhancement in the early phase followed by rapid wash‐out and demarcation of the lesion without contrast enhancement in the parenchymal phase (60 seconds after injection) was typical for malignant lesions (P < .001). Conclusions. Contrast‐enhanced ultrasonography is helpful in the differentiation between benign and malignant lesions of the spleen.     

Dieulafoy's lesion: management and long-term outcome

BACKGROUND AND STUDY AIMS: Dieulafoy's lesion is usually considered to be a rare cause of gastrointestinal bleeding and little information is available about the long-term follow-up of this condition. We studied the clinical pattern and long-term outcome in patients with Dieulafoy's lesion who were managed in a gastrointestinal intensive care unit. PATIENTS AND METHODS: We reviewed the data on the diagnosis, treatment, and outcome of 70 patients admitted to our unit for acute upper gastrointestinal bleeding due to Dieulafoy's lesion. Endoscopic hemostasis was performed in 69 cases. Patients underwent surgery if endoscopic therapy failed. A phone interview was carried out to assess the long-term clinical outcome. RESULTS: Dieulafoy's lesion accounted for 4 % of cases of upper gastrointestinal bleeding in patients admitted during the period studied. The mean number +/- SD of endoscopies required to establish the diagnosis was 1.4 +/- 0.75. Endoscopic hemostasis was initially successful in 91.3 % of patients, while nearly 16 % of patients required surgery because endoscopic therapy failed. The overall mortality rate was 8.6 %. None of the 52 patients who were followed up by phone reported recurrent bleeding after discharge from hospital, in a mean follow-up period of 69 months. CONCLUSIONS: Dieulafoy's lesion is a not uncommon cause of severe recurrent gastrointestinal bleeding. Endoscopic therapy is safe and effective in achieving permanent hemostasis. The long-term prognosis for Dieulafoy's lesion is excellent, even when patients are treated using endoscopic methods alone.     

Pseudolymphoma of the liver: Sonographic findings and review of the literature

We report a case of hepatic pseudolymphoma in a 67-year-old woman that was detected during an abdominal sonography screening. The lesion was further evaluated using CT, MRI, angiography, and contrast-enhanced sonography. The imaging features of this tumor are discussed herein. The diagnosis of pseudolymphoma was achieved via sonographically guided biopsy. The lesion regressed completely within 1 year.     

Sonoelastographic Strain Index for Differentiation of Benign and Malignant Nonpalpable Breast Masses

Objective. The purpose of this study was to evaluate the diagnostic potential of the sonoelastographic strain index for differentiation of nonpalpable breast masses. Methods. Ninety‐nine nonpalpable breast masses (79 benign and 20 malignant) in 94 women (mean age, 45 years; range, 21–68 years) who had been scheduled for a sonographically guided core biopsy were examined with B‐mode sonography and sonoelastography. Radiologists who had performed the biopsies analyzed the B‐mode sonograms and provided American College of Radiology Breast Imaging Reporting and Data System categories. The strain index (fat to lesion strain ratio) was calculated by dividing the strain value of the subcutaneous fat by that of the mass. The histologic result from the sonographically guided core biopsy was used as a reference standard. The diagnostic performance of the strain index and that of B‐mode sonography were compared by receiver operating characteristic (ROC) curve analysis. Results. The mean strain index values ± SD were 6.57 ± 6.62 (range, 1.29–28.69) in malignant masses and 2.63 ± 4.57 (range, 0.54–38.76) in benign masses (P = .019). The area under the ROC curve values were 0.835 (95% confidence interval [CI], 0.747–0.902) for B‐mode sonography and 0.879 (95% CI, 0.798–0.936) for the strain index (P = .490). The sensitivity, specificity, positive predictive value, and negative predictive value were 95% (19 of 20), 75% (59 of 79), 48% (19 of 39), and 98% (59 of 60), respectively, when a best cutoff point of 2.24 was used. Conclusions. The strain index based on the fat to lesion strain ratio has diagnostic performance comparable with that of B‐mode sonography for differentiation of benign and malignant breast masses.     

Diagnostic accuracy of sonography and combined sonographic assessment and sonographically guided cytology in nonpalpable solid breast lesions

PURPOSE: The aim of this study was to assess the diagnostic accuracy of sonography alone and combined sonographic assessment and sonographically guided fine-needle aspiration cytology in solid, nonpalpable lesions of the breast. METHODS: We retrospectively evaluated the sonograms from a series of 174 consecutive nonpalpable masses that were cytologically diagnosed using fine-needle aspiration under sonographic guidance and then histologically verified through surgical excision. We examined the relationships between the findings from sonography, combined sonographic assessment and cytopathology, and histology. RESULTS: Histologically, 95 lesions (55%) were malignant and 79 (45%) were benign. The overall sensitivity of sonography alone for diagnosing cancer was 98. 9% (94 of 95 lesions), and the specificity was 45.6% (36 of 79 lesions). One (3%) of 37 masses considered at sonography to be benign was correctly diagnosed on cytologic examination to be cancer. By establishing the benign status of 11 of 13 masses that were indeterminate at sonography, cytology increased the specificity of the combined method (to 56.3%). Cytology appropriately suspected or confirmed malignancy in 79 (84%) of 94 carcinomas considered at sonography to be suspicious or malignant. CONCLUSIONS: In this study, sonography alone demonstrated a high sensitivity but limited specificity in evaluating nonpalpable breast masses. The addition of sonographically guided cytology substantially increased the specificity of the combined method without compromising sensitivity.     

Feasibility of Sonography for Intra‐articular Injections in the Knee Through a Medial Patellar Portal

Objective. The purpose of this study was to investigate the feasibility of using real‐time high‐resolution sonography to guide an injection needle into the intra‐articular space within the knee. Methods. Eighty‐nine patients with radiographically confirmed knee osteoarthritis (Kellgren‐Lawrence grade 2 or 3) without an effusion were included. After sonographically guided or blind injection of hyaluronic acid (HA) and contrast dye through a medial patellar portal (MPP) into the knee joint, a radiographic image was made to ascertain whether the injected material had reached the intra‐articular space. Result. Sonographically guided injections of HA into the knee joint had a significantly greater accuracy rate (95.6%) than blind injections (77.3%; P = .01). Conclusions. Intra‐articular injections via an MPP using sonographic guidance may raise the accuracy rate in knee joint injections.     

Osteochondritis dissecans of the knee: sonographically guided percutaneous drilling.

OBJECTIVE: The purpose of this study was to present a procedure for sonographically guided percutaneous drilling in the treatment of a case of osteochondritis dissecans (OD) of the knee. METHODS: A 14-year-old boy had OD of the external femoral condyle. Conventional radiography, magnetic resonance imaging, and sonography revealed the osteochondral lesion. RESULTS: This study showed the utility of sonography both in the treatment of OD through percutaneous drilling and in follow-up. CONCLUSIONS: On the basis of the good results obtained in the case described here, it is thought that sonographically guided percutaneous drilling may be a good alternative to arthroscopic drilling in cases of early OD lesions without displacement of the fragment.     

超声造影在诊断腹部实质脏器损伤及引导微创止血治疗中的作用

目的探讨超声造影在诊断腹部实质脏器损伤及引导微创止血治疗的价值。方法对临床疑为肝脾破裂的患者行超声造影检查,并对损伤程度进行分级。根据超声造影和cT诊断结果,对损伤程度为3～4级、生命体征平稳的患者行超声造影引导下微创止血治疗。结果48例患者中35例超声造影确诊为实质脏器损伤,均经手术或cT证实。11例患者成功在超声造影引导下进行了肝脾脏器的微创止血治疗,治疗中和治疗后无明显不适。结论超声造影可准确诊断肝脾损伤并判断程度,其引导的微创止血治疗对生命体征平稳的患者可实现安全、有效的止血,是非手术治疗的一种良好方法。     

Contrast‐Enhanced Ultrasound Guidance for Interventional Procedures

Since its introduction, contrast‐enhanced ultrasound (CEUS) has gained an important role in the diagnosis and management of abdominal and pelvic diseases. Contrast‐enhanced ultrasound can improve lesion detection rates as well as success rates of interventional procedures when compared to conventional ultrasound alone. Additionally, CEUS enables the interventionalist to assess the dynamic enhancement of different tissues and lesions, without the adverse effects of contrast‐enhanced computed tomography, such as exposure to ionizing radiation and nephrotoxicity from iodinated contrast material. This review article describes the various applications and advantages of the use of CEUS to enhance performance of ultrasound‐guided interventions in the abdomen and pelvis.