The Nipple‐Areolar Complex

Objective. The purpose of this presentation is to show the radiologic findings of normal variants and benign and malignant diseases that affect the nipple‐areolar complex. Methods. We evaluated the imaging findings of nipple‐areolar complex lesions, using multiple breast imaging modalities including mammography, sonography, galactography, contrast‐enhanced magnetic resonance imaging (MRI), and positron emission tomography/computed tomography. Results. Radiologic features of nipple‐areolar complex lesions, including Montgomery tubercles, nipple inversion, benign calcifications, inflammation, duct dilatations, intraductal papillomas, fibroadenomas, neurofibromatosis, dermatosis of the nipple, and breast malignancy, have been illustrated. Conclusions. A clinical examination is essential and an appropriate imaging evaluation with multiple modalities is often necessary to accurately diagnose an underlying abnormality of the nipple‐areolar complex. Given the limitations of conventional mammography, supplemental mammographic views often are needed, and sonography may be performed to further characterize a mammographic or clinical finding. Also, contrast‐enhanced MRI may be useful for additional evaluation.     

Novel Use of Contrast‐Enhanced Sonography in the Diagnosis of Central Uterine Necrosis Following Embolization for Postpartum Hemorrhage

Since 2007, we have identified 2 cases of central uterine necrosis after uterine arterial embolization for postpartum hemorrhage. Contrast‐enhanced sonography showed an absence of enhancement of the internal myometrium. Magnetic resonance imaging with gadolinium confirmed the diagnosis. The images obtained for the first case were corroborated by histologic analysis from a hysterectomy done for sepsis. For the second case, contrast‐enhanced sonography performed during a follow‐up period of conservative treatment revealed a reduction of necrosis. Our study shows that contrast‐enhanced sonography seems to be a useful examination as an adjunct to grayscale and power Doppler imaging in the diagnosis and follow‐up of uterine necrosis.     

Regional heterogeneity changes in DCE‐MRI as response to isolated limb perfusion in experimental soft‐tissue sarcomas

Experimental evidence supports an association between heterogeneity in tumor perfusion and response to chemotherapy/radiotherapy, disease progression and malignancy. Therefore, changes in tumor perfusion may be used to assess early effects of tumor treatment. However, evaluating changes in tumor perfusion during treatment is complicated by extensive changes in tumor type, size, shape and appearance. Therefore, this study assesses the regional heterogeneity of tumors by dynamic contrast‐enhanced MRI (DCE‐MRI) and evaluates changes in response to isolated limb perfusion (ILP) with tumor necrosis factor alpha and melphalan. Data were acquired in an experimental cancer model, using a macromolecular contrast medium, albumin–(Gd–DTPA)45. Small fragments of BN 175 (a soft‐tissue sarcoma) were implanted in eight brown Norway rats. MRI of five drug‐treated and three sham‐treated rats was performed at baseline and 1 h after ILP intervention. Properly co‐registered baseline and follow‐up DCE‐MRI were used to estimate the volume transfer constant (K^trans) pharmacokinetic maps. The regional heterogeneity was estimated in 16 tumor sectors and presented in cumulative map‐volume histograms. On average, ILP‐treated tumors showed a decrease in regional heterogeneity on the histograms. This study shows that heterogenic changes in regional tumor perfusion, estimated using DCE‐MRI pharmacokinetic maps, can be measured and used to assess the short‐term effects of a potentially curative treatment on the tumor microvasculature in an experimental soft‐tissue sarcoma model. Copyright © 2013 John Wiley & Sons, Ltd.     

The role of power Doppler sonography in the evaluation of superficial soft tissue abscesses

Objective: To evaluate the efficacy of power Doppler ultrasonography in depicting increased vasculature and hyperemia around the superficial soft tissue abscess. Materials and methods: 21 patients with soft tissue abscess were evaluated with gray scale imaging, color Doppler sonography, power Doppler sonography and computed tomography. In each case attempts were made using power Doppler sonography to demonstrate any areas of increased vascularity around the lesion. The results were compared with computed tomographic findings. Results: Peripheral hyperemia and increased vasculature were demonstrated with power Doppler sonography in 19 of 21 patients with soft tissue abscess. The hyperemic area demonstrated around the wall of the abscess by power Doppler sonography was similar to the enhanced area shown by computed tomography performed after contrast administration. Conclusion: Power Doppler sonography shows increased vasculature and hyperemia in the wall of abscesses. Therefore, power Doppler sonography can be used to assist with the diagnosis of superficial soft tissue abscess.     

Neoadjuvant HIFU treatment for malignant fibrous histiocytoma: report of a case

High-intensity focused ultrasound (HIFU) is an innovative, noninvasive, extracorporeal technique that induces coagulative necrosis of tumor tissue by thermal effects and cavitation. In published studies, HIFU has usually been used as an alternative to surgery, with or without other treatment modalities, to achieve curative tumor ablation or palliative tumor cytoreduction. Neoadjuvant HIFU treatment for primary inoperable malignant fibrous histiocytoma has never been reported, and neoadjuvant radiotherapy, chemoradiation, or chemotherapy is routinely under consideration. This is the first case in which HIFU ablation contributed as a neoadjuvant therapy to facilitate function-sparing resection, not as a replacement for surgery. It suggests that HIFU ablation may have some unique major advantages for treating inoperable huge soft-tissue sarcomas as a neoadjuvant local treatment modality, especially for patients for whom neoadjuvant chemotherapy or radiotherapy is not indicated.     

Ablation therapy guided by contrast-enhanced sonography with Sonazoid for hepatocellular carcinoma lesions not detected by conventional sonography.

OBJECTIVE: We evaluated the usefulness of contrast-enhanced harmonic gray scale sonography with a newly developed sonographic contrast medium as a means of guidance for percutaneous ablation therapy of hepatocellular carcinoma lesions not detected by conventional sonography. METHODS: We examined 85 patients with 108 hepatocellular carcinoma lesions that were identified as hypervascular by multidetector-row computed tomography by using contrast-enhanced harmonic gray scale sonography after injection of Sonazoid (GE Healthcare, Oslo, Norway), a lipid-stabilized suspension of a perfluorobutane gas microbubble contrast agent. We scanned the whole liver by this modality at a low mechanical index in the late phase to detect lesions not detected by conventional sonography and then scanned the lesions again by this modality at a high mechanical index to visualize tumor vessels and enhancement. We also performed percutaneous ablation therapy guided by this modality to treat viable hepatocellular carcinoma lesions that could not be detected by conventional sonography. RESULTS: Conventional sonography identified 90 (83%) of 108 hepatocellular carcinoma lesions; 15 (14%) additional viable lesions not detected by conventional sonography were detected in the late phase of contrast-enhanced harmonic gray scale sonography at a low mechanical index, and tumor vessels and enhancement were observed in the late phase at a high mechanical index. Contrast-enhanced harmonic gray scale sonography diagnosed 105 (97%) of the 108 viable hepatocellular carcinoma lesions, and 14 (93%) of the 15 lesions not detected by conventional sonography were successfully treated by percutaneous ablation therapy guided by this modality. CONCLUSIONS: Contrast-enhanced harmonic gray scale sonography is useful for guidance of percutaneous ablation therapy of hepatocellular carcinoma lesions not detected by conventional sonography.     

Contrast‐Enhanced Sonographic Characteristics of Hepatic Inflammatory Pseudotumors

A hepatic inflammatory pseudotumor, which can be misdiagnosed as a malignant tumor, is a relatively uncommon tumor with nonspecific imaging manifestations. As a new diagnostic technique, contrast‐enhanced sonography has become increasingly important in the diagnosis of liver focal lesions. Here we present 3 cases of histologically confirmed hepatic inflammatory pseudotumors diagnosed with contrast‐enhanced sonography. “Fast‐in and centrifugal‐out” may be a characteristic contrast‐enhanced sonographic enhancement pattern in the diagnosis of hepatic inflammatory pseudotumors, which needs confirmation in further studies.     

Sonographic evaluation of early-stage breast cancers that undergo neoadjuvant chemotherapy.

OBJECTIVE: We prospectively evaluated low-stage breast cancers treated with neoadjuvant chemotherapy using whole-volume sonography and color Doppler imaging. METHODS: Thirty-four women with breast cancer (mean maximum size, 2.4 cm) received neoadjuvant chemotherapy with doxorubicin and docetaxel. Targeted whole-volume sonography of tumor sites was performed before and after chemotherapy to assess mass size, color pixel speed-weighted density, and American College of Radiology Breast Imaging Reporting and Data System sonographic characteristics. After chemotherapy, tumor sites were excised by lumpectomy or mastectomy. RESULTS: Three (11.3%) of 34 patients had a complete histologic response. After chemotherapy, correlation was r = 0.716 between final histologic and sonographic sizes. Compared with histologic residual tumors, sonography had 4 false-negative results, 3 false-positive results, and 27 true-positive results (sensitivity, 87%), with no false-negative results among a subgroup of tumors of 7 mm and larger (sensitivity, 100%). The 3 cases with false-positive results were histologic fibrosis or biopsy changes. Mean speed-weighted density was 0.015 before and 0.0082 after chemotherapy (P = .03). After chemotherapy, vascularity was less common within (P = .06) or adjacent to (P = .009) masses or in tumor sites (P = .05). Prechemotherapy variables of gray scale characteristics and vascularity were compared with final histologic size, and all had P > .20. CONCLUSIONS: Postchemotherapy sensitivity of sonography was high for residual tumors of 7 mm or larger. Correlation was moderate between histologic and sonographic final tumor sizes. False-positive results were caused by fibrosis or biopsy-related changes. False-negative results occurred with residual tumor size of 6 mm or smaller. After chemotherapy, vascularity usually decreased, and this was not specific for complete response. Before chemotherapy, no vascular or gray scale feature at initial imaging predicted complete responders.     

Transient bilateral ovarian enlargement associated with large retroperitoneal lymphoma.

Bilateral ovarian enlargement may reflect benign or malignant processes of the ovary. Benign causes of ovarian enlargement include luteomas, tumors such as mature cystic teratomas, fibrothecomas, cystadenomas and rare conditions including capillary hemangioma and massive edema of the ovaries. Ovarian malignancies include epithelial, stromal and germ-cell tumors. Primary malignancies that may exhibit metastases to the ovaries include gastrointestinal, breast and soft tissue tumors such as lymphoma. We present an unusual case in which a patient presenting with weakness and mild lower abdominal and pelvic pain was noted at sonography to have bilaterally enlarged ovaries with features similar to those of massive ovarian edema as described previously, which has been associated with venous and lymphatic obstruction. Subsequent computerized tomography (CT) imaging depicted a large retroperitoneal tumor, CT-guided biopsy of which revealed diffuse large B cell lymphoma. The patient responded well to chemotherapy with significant shrinkage of the tumor, and reappearance of normal findings on ovarian sonography. This case demonstrates that bilaterally enlarged ovaries may be the first clinical evidence of a large retroperitoneal tumor and that in such cases CT imaging may be warranted.     

Imaging tumor response following liver-directed intra-arterial therapy

Liver-directed intra-arterial therapies are palliative treatment options for patients with unresectable liver cancer; their use has also resulted in patients being downstaged leading to curative resection and transplantation. These intra-arterial therapies include transarterial embolization, conventional transarterial chemoembolization (TACE), drug-eluting bead TACE and radioembolization. Assessment of imaging response following these liver-directed intra-arterial therapies is challenging but pivotal for patient management. Size measurements based on computed tomography or magnetic resonance imaging (MRI) have been traditionally used to assess tumor response to therapy. However, these anatomic changes lag behind functional changes and may require months to occur. Further, these intra-arterial therapies cause acute tumor necrosis, which may result in a paradoxical increase in tumor size on early follow-up imaging despite complete cell death or necrosis. This concept is unique comparing to changes seen following systemic chemotherapy. The recent development of functional imaging techniques including diffusion-weighted MRI (DW MRI) and positron emission tomography (PET) allow for early assessment of treatment response and even prediction of overall tumor response to intra-arterial therapies. Although the results of DW MRI and PET studies are promising, the impact of these imaging modalities to assess treatment response has been limited without standardized protocols. The aim of this review article is to delineate the best practice for assessing tumor response in patients with primary or secondary hepatic malignancies undergoing intra-arterial therapies.     

躯干和肢体软组织肉瘤的围手术期化疗与放疗

虽然手术是肢体和躯干原发软组织肉瘤的根治性治疗手段,但对于高危患者单纯手术常难以获得疾病的长期控制。治疗失败的主要原因为远处转移,其次为局部复发。一些局部进展期的患者可能面临无法手术切除,或仅边缘可切除,因此预后很差。围手术期的系统治疗和放疗可提高手术疗效。如何确立围手术期系统治疗的价值颇具挑战。系统治疗可以缩小肿瘤。但要证明其对局部控制的价值从而促进实施更为保守的外科手术的证据仍不充分。对于那些原发肿瘤被认定为难以或不可能切除的患者,新辅助化疗可能为疾病的局部控制提供一种选择。围手术期的系统治疗也可以避免远处转移的发生。近期的研究表明,以蒽环类药物/异环磷酰胺为基础的辅助治疗能够使患者获益,虽然证据来自于对一项大型研究的再次分析。一项新辅助化疗的随机研究提示,对某些经过选择的肉瘤组织学亚型,以蒽环类药物/异环磷酰胺为基础的系统化疗可能改善患者无病生存和总生存期。其疗效的获得主要是通过改善远处无转移生存而不是局控率的提高。这两项研究所采用的方法均存在一定的局限性,因此需要进一步探索。尽管如此,我们相信这些结果支持在局部进展期、肢体和躯干原发的软组织肉瘤患者中进行新辅助化疗。放疗与手术结合在软组织肉瘤的治疗中有确切的疗效。虽然预后并不因放疗和手术的先后顺序而异,但不良反应却存在差异。辅助放疗较新辅助放疗有更低的围手术期伤口并发症,但相对于新辅助放疗而言,辅助放疗需要更高的放射剂量,对长期功能的预后差于新辅助放疗。因此,我们相信围手术期放疗与化疗一样,在可能的情况下,应尽可能在术前进行。     

Echo-enhancing sonography of a large-vessel hemangioma of the neck.

Because of the slow flow in the venous spaces of large-vessel hemangiomas, demonstration of color flow signals with conventional color Doppler or power Doppler sonography may be difficult. We report the case of a 22-year-old female patient with a soft tissue tumor containing multiple fluid-filled spaces in the right supraclavicular region. Gray-scale, color, and power Doppler sonography could not differentiate between cystic lymphangioma and large-vessel hemangioma. The intravenous echo-enhancing contrast agent Levovist was administered, and a significant echo-enhancing effect on color and power Doppler imaging was demonstrated in the fluid-filled spaces and lasted for about 3 minutes. Histopathologic study of the excised tumor confirmed the sonographic diagnosis of hemangioma. Levovist appears useful in depicting slow flow in a large-vessel hemangioma.     

Primary primitive neuroectodermal tumor in the pericardium—a focus on imaging findings: A case report

BACKGROUNDPrimitive neuroectodermal tumors (PNETs) are rare, sporadic malignant tumors of the peripheral nervous system, bone, or soft tissues. However, to the best of our knowledge, only three cases of PNET in the pericardium have been reported in the English literature, and their magnetic resonance imaging findings have not previously been described.CASE SUMMARYA 3-year-old boy was hospitalized with a 1-wk history of recurrent vomiting and weakness. Detailed history-taking revealed no evidence of heart disease. Computed tomography demonstrated a soft tissue mass in the left pericardial cavity with heterogeneous contrast enhancement. The border between the mass and the heart was poorly defined. Thoracotomy revealed a mass invading the left ventricle, with a high risk of bleeding. The mass was considered inoperable. A biopsy was performed, and the histological and immunohistochemical findings confirmed the diagnosis of primary PNET of the pericardium. The patient received four cycles of standard chemotherapy. Chest magnetic resonance imaging 3 mo after the initiation of chemotherapy revealed that the tumor in the pericardium still existed, but its volume had slightly decreased. The patient was lost to follow-up, and the final outcome was therefore unknown.CONCLUSIONMedical imaging plays an important role in defining the pericardial origin of PNET and understanding its characteristics. Magnetic resonance imaging can provide more information on the tumor than computed tomography and may thus aid therapeutic planning.     

Correlation of Quantified Contrast‐Enhanced Sonography With In Vivo Tumor Response

Objective.. The purpose of our study was to establish in vivo criteria for monitoring tumor treatment response using 3‐dimensional (3D) volumetric gray scale, power Doppler, and contrast‐enhanced sonography. Methods.. Twelve mice were implanted with Lewis lung carcinoma cells on their hind limbs and categorized to 4 groups: control, chemotherapy, radiation therapy, and chemoradiation. A high‐frequency ultrasound system with a 40‐MHz probe was used to image the tumors. Follow‐up contrast‐enhanced sonography was performed on days 7 and 14 of treatment with two 50‐μL boluses of a perflutren microbubble contrast agent injected into the tail vein. The following contrast‐enhanced sonographic criteria were quantified: time to peak, peak intensity, α (microvessel cross‐sectional area), and β (microbubble velocity). Three‐dimensional power Doppler images were also obtained after the acquisition of contrast data. On day 15, the tumors were excised for immunohistochemical analysis with CD31 fluorescent staining. Results.. The tumor size and 3D power Doppler vascular index showed no statistically significant correlation with microvascular density in all examined groups. Among all of the analyzed contrast‐enhanced sonographic parameters, relative α showed the strongest correlation with the histologic microvessel density (Pearson r = 0.93; P < .01) and an independent association with the histologic data in a multiple regression model (beta = .93; R² = 0.86; P < .01). Conclusions.. Of the various examined sonographic parameters, α has the strongest correlation with histologic microvessel density and may be the parameter of choice for the noninvasive monitoring of tumor angiogenic response in vivo.     

Five Cases of Axillary Lymph Node Metastatic Breast Cancer on Contrast‐Enhanced Sonography

This study was performed to determine the importance of contrast‐enhanced sonography for axillary lymph node metastatic breast cancer. Contrast‐enhanced sonographic findings in 5 patients with breast cancer and axillary lymph node metastasis are discussed, and imaging‐pathologic correlations are also presented in 3 cases. In all 5 cases, lymph nodes showed a perfusion defect in the late phase. Rapid arterial enhancement and wash‐out were observed in 2 cases in which we performed second injections. Contrast‐enhanced sonography may be effective for identifying metastatic lesions in lymph nodes, especially in the early stages.     

Photoacoustic Imaging of the Bladder

Photoacoustic imaging is a promising new technology that combines tissue optical characteristics with ultrasound transmission and can potentially visualize tumor depth in bladder cancer. We imaged simulated tumors in 5 fresh porcine bladders with conventional pulse‐echo sonography and photoacoustic imaging. Isoechoic biomaterials of different optical qualities were used. In all 5 of the bladder specimens, photoacoustic imaging showed injected biomaterials, containing varying degrees of pigment, better than control pulse‐echo sonography. Photoacoustic imaging may be complementary to diagnostic information obtained by cystoscopy and urine cytologic analysis and could potentially obviate the need for biopsy in some tumors before definitive treatment.     

Bedside Contrast‐Enhanced Sonography of Critically Ill Patients

The transfer of critically ill patients to the radiology department is, in itself, potentially dangerous, so radiologists are frequently asked to perform bedside sonographic studies in the intensive care unit, surgical or medical department, sterile area, and operating room. In these circumstances, injection of a contrast agent may give the radiologist relevant additional information, which is useful for diagnosis and for better therapeutic management of these critically ill patients. Contrast‐enhanced sonography may allow detection of findings not recognizable on baseline sonography or even color Doppler imaging. In this pictorial essay, we highlight the value of real‐time contrast‐enhanced sonography when performed at the bedside in critically ill patients.     

兔VX-2肝肿瘤MRI表现和病理对照研究

目的:评价MRI对兔VX-2肝癌存活肿瘤、肿瘤坏死和出血的显示能力。方法:10只兔肝内接种VX-2肝癌后14 d行MRI扫描。检查后处死动物行病理检查。MRI表现与病理结果对照。结果:(1)MRI表现:10只兔共有病灶18个。病灶在SE T1WI上为低信号,T2WI上为不均匀高信号。动态增强早期病灶有不均匀强化,以环状强化为主,增强晚期仍见强化。(2)病理:所有标本均有不同程度的凝固性坏死。6个直径大于1．5 cm的病灶内见凝固性坏死伴出血。(3)MRI与病理对照,T1WI低信号为肿瘤组织、坏死; T2WI高信号为肿瘤组织、坏死伴出血,低信号为凝固性坏死。动态增强有强化区为肿瘤组织,无强化为坏死、出血。结论:(1)兔VX- 2肝癌可发生自发性凝固性坏死和出血等改变。(2)MRI,尤其是动态增强能准确显示兔VX-2肝癌的肿瘤组织、坏死和出血。     

Clinically unsuspected foreign bodies: the importance of sonography.

OBJECTIVE: To show the value of sonography in the detection of clinically unsuspected foreign bodies appearing as soft tissue masses. METHODS: High-resolution B-mode and color Doppler sonography was performed in 288 patients referred with superficial soft tissue masses over a period of 2 years. RESULTS: In 8 lesions in 6 patients, sonography showed small curved or linear echogenic structures surrounded by hypoechoic masses characteristic of foreign bodies with granulation tissue. One lesion had increased vascularity on color Doppler sonography. Patients were referred for other imaging studies, including magnetic resonance imaging, computed tomography, and bone and labeled red blood cell scintigraphy, which did not add relevant information. Three patients underwent surgery; foreign bodies were found in 2, and infected granulation tissue was found in 1. Spontaneous resolutions and no growth of the lesions were seen in the other 2 patients. CONCLUSIONS: The possibility of a foreign body should be considered when scanning soft tissue masses even in the absence of a relevant clinical history. Once a foreign body is diagnosed, no further workup is indicated.     

Advantages of color B-mode imaging with contrast optimization in sonography of low-contrast musculoskeletal lesions and structures in the foot and ankle.

OBJECTIVE: The purpose of this study was to evaluate the utility of color B-mode imaging with contrast optimization in evaluating low-contrast lesions of the foot and ankle (Morton neuromas and plantar fasciitis). METHODS: The sonographic examinations of 49 consecutive patients with a diagnosis of plantar fasciitis or Morton neuroma imaged with both conventional gray scale imaging and color B-mode imaging with contrast optimization (Photopic; Siemens Medical Solutions, Mountain View, CA) were reviewed. In every patient, matched pairs of images obtained with conventional gray and color maps (Photopic) were acquired and stored as DICOM (Digital Imaging and Communications in Medicine) images on a sonographic workstation. Each image was assessed independently by 2 musculoskeletal radiologists trained in musculoskeletal sonography for overall image contrast (lesion to background), conspicuity of regional tissue boundaries, visualization of deep tissue boundaries, and how well the internal characteristics of the structure were visualized. RESULTS: Three-way analysis of variance showed that Photopic imaging resulted in statistically significantly improved overall image contrast, definition of regional soft tissue boundaries, including deep soft tissue boundaries, and depiction of the internal characteristics of the structure being examined. CONCLUSIONS: Color imaging with contrast optimization improves overall image contrast and better defines deep soft tissue boundaries and the internal morphologic characteristics of Morton neuromas and the plantar fascia compared with conventional gray scale imaging.