High-frequency scrotal sonography

High-frequency real-time sonography has enhanced accuracy in the diagnosis of scrotal abnormalities. Results of 48 scrotal scans of 92 testes are presented. There were 22 testicular lesions, nine seminomas, four embryonal cell carcinomas, one case of metastatic prostatic carcinoma, one benign "keratin cyst," three testicular infarcts, three atrophied testes, and one case of testicular torsion. Hypoechoic tumors and infarcts have a similar appearance. Extratesticular abnormalities included spermatoceles, varicoceles, epididymitis, hydroceles, and a scrotal hematoma. Sonography accurately distinguished between testicular and extratesticular masses in all cases in this series and pathologic correlations were obtained for all testicular masses. Simultaneous real-time contact scanning and palpation facilitated accurate diagnosis.     

Preoperative sonography of malignant ovarian neoplasms

Patient survival in malignant ovarian tumors is directly dependent on complete surgical resection. This can be best accomplished when the surgeon is informed of tumor extent preoperatively. We retrospectively studied the preoperative sonograms of 32 patients with proven malignant ovarian tumors. Results were compared with the surgical and pathologic findings. Sonography was 97% accurate in the detection and 84% accurate in the characterization of the pelvic masses; 87.5% of these tumors were malignant by sonographic criteria. Sonography correctly staged only 48% of patients. Bowel and bladder involvement, of major importance in planning surgical treatment, were not detected by sonography. A uterus inseparable from a pelvic mass correlated with uterine involvement in 74% and this information alone may prevent laparotomy by surgeons unprepared to perform the complete resection necessary for optimum survival.     

Scrotal enlargement following inguinal herniorrhaphy: Ultrasound evaluation

Although sonography has become an established modality in the evaluation of acute and chronic scrotal abnormalities, its role in the post-herniorrhaphy patient with scrotal swelling has not yet been defined. We present 5 patients with immediate and delayed complications of herniorrhaphy in which sonography provided useful clinical information. Immediate complications included scrotal hematomas, scrotal wall and septal thickening, epididymitis, and testicular displacement. Delayed complications included an infected hydrocele demonstrating a fluid-debris level. The etiology of scrotal swelling in postherniorrhaphy patients can be determined with sonography.     

Scrotal enlargement following inguinal herniorrhaphy: ultrasound evaluation

Although sonography has become an established modality in the evaluation of acute and chronic scrotal abnormalities, its role in the post-herniorrhaphy patient with scrotal swelling has not yet been defined. We present 5 patients with immediate and delayed complications of herniorrhaphy in which sonography provided useful clinical information. Immediate complications included scrotal hematomas, scrotal wall and septal thickening, epididymitis, and testicular displacement. Delayed complications included an infected hydrocele demonstrating a fluid-debris level. The etiology of scrotal swelling in postherniorrhaphy patients can be determined with sonography.     

The normal and abnormal scrotum in children: evaluation with color Doppler sonography.

The use of color Doppler sonography to evaluate the symptomatic testes in children with scrotal pain or swelling was prospectively studied with a fourth-generation color sonographic unit with a 7-MHz linear transducer. The 32 patients were 1 day to 18 years old (mean age, 8.6 years). Results were correlated with scintigraphic findings in 23 patients, with the final diagnosis established by surgery in 12 patients, and with clinical follow-up in all patients. Eight cases of testicular torsion, including two of acute torsion and six of late torsion, were correctly detected by color Doppler sonography and confirmed surgically. In the remaining patients, perfusion of the testis was correctly detected by color Doppler examination. The final diagnoses in these patients included torsion of the appendix testis (15 patients), epididymitis (five patients), epididymo-orchitis (one patient), yolk sac tumor of the testis (one patient), hydrocele (one patient), and local reaction to an insect bite (one patient). The ability to detect blood flow in the normal contralateral testis was also evaluated in 28 patients. Blood flow was demonstrated in normal testes larger than 1 cm3. Detection of flow in the very small normal prepubertal testis was often difficult, and no flow was identified in one testis. Flow was identified in central arteries in only six of 13 testes smaller than 1 cm3. We conclude that color Doppler sonography is helpful in the initial evaluation of pediatric testes, providing accurate evaluation of the involved hemi-scrotum in our patients and also providing the benefit of both structural and flow information. Until our sensitivity to low-velocity flow improves, we would not suggest the exclusive use of color Doppler sonography in the evaluation of testicular perfusion in the prepubertal patient. We advocate the addition of testicular scintigraphy to corroborate the presence of testicular perfusion when flow in intratesticular arteries cannot be established with certainty by color Doppler sonography.     

Asymptomatic scrotal masses in children

The ultrasound scans of 16 boys with asymptomatic scrotal masses were retrospectively studied. Ultrasound localized seven of the masses as primary testicular lesions and nine as extratesticular lesions, six of which were hydroceles. Ultrasonography also characterized the scrotal masses as predominantly cystic or solid. Ultrasound could not differentiate benign from malignant disease when a solid mass was found. When a hydrocele was identified, ultrasound was able to image the underlying testis and accurately evaluate it for primary disease. These ultrasound observations can help the surgeon decide when to explore the scrotum and whether to approach the testes via an inguinal or scrotal incision. Conversely, ultrasonographic confirmation of a normal testis may prevent needless surgery and the removal of a normal testis.     

Comparison of tuberculous and pyogenic epididymal abscesses: clinical, gray-scale sonographic, and color Doppler sonographic features

OBJECTIVE: The purpose of this study was to evaluate the capability of clinical, gray-scale sonographic, and color Doppler sonographic features for differentiating tuberculous and pyogenic epididymal abscesses. MATERIALS AND METHODS: Retrospective analysis was performed in 10 cases of tuberculous epididymal abscess and in 13 cases of pyogenic epididymal abscess. The following clinical, gray-scale sonographic, and color Doppler sonographic features were analyzed: patient's age; duration of symptoms; scrotal tenderness; presence of sinus tract; concurrent tuberculosis in other organs; location, size, and echogenicity of the abscess; hyperechoic rim; testicular involvement; hydrocele; and blood flow in the epididymal lesion. RESULTS: Tuberculous epididymal abscess had a longer duration of symptoms (p = 0.0001) and a lower frequency of scrotal tenderness (p = 0.0048) than pyogenic epididymal abscess. The size of the abscess was larger in tuberculous epididymal abscess than in pyogenic epididymal abscess (p = 0.0002). The degree of blood flow in the peripheral portion of the abscess was lower in tuberculous epididymal abscess (p = 0.001). The patient's age, location and echogeninicity of the abscess, presence of sinus tract, hyperechoic rim, testicular involvement, and hydrocele did not differ between the tuberculous and pyogenic epididymal abscesses. CONCLUSION: Some clinical findings, gray-scale sonography, and color Doppler sonography were useful in differentiating tuberculous epididymal abscess from pyogenic epididymal abscess. The presence of long-term scrotal swelling without tenderness and a lower degree of blood flow in the peripheral portion of a large abscess are suggestive of tuberculous epididymal abscess.     

Combined mammographic-sonographic evaluation of breast masses.

Palpable breast masses which have a nondiagnostic appearance on the mammogram often require a biopsy to rule out malignancy. Contact B-scan ultrasonography of such masses were performed in an effort to improve the diagnostic accuracy of mammography and reduce the number of unnecessary biopsies. A total of 200 patients with breast masses of 1-8 cm were examined by both methods. The results of this combined evaluation were compared to those of mammography alone. Of 115 pathologically proven lesions, 44 were fluid-filled cysts. Sonography correctly diagnosed all 44 cysts, while mammography was equivocal in 27 (61%) of them. Of the remaining 71 solid masses, 38 were benign and 33 malignant. Mammography alone correctly diagnosed 31 carcinomas (94%), whereas sonography correctly diagnosed 26 (78.8%). While the infiltrating carcinomas have a typical sonographic appearance, circumscribed carcinomas may have the same sonographic features as fibroadenomas; the value of sonography here was to establish whether the mass was solid. In other solid masses such as those produced by dysplasias, abscesses, and mastitis, sonography was helpful in differentiating between diffuse and discrete lesions. The combined mammographic-sonographic evaluation of breast masses was more accurate than either method alone.     

Prevalence and significance of heterogeneous testes revealed on sonography: ex vivo sonographic-pathologic correlation

OBJECTIVE: Heterogeneous or mottled testes in middle-aged or elderly men are often encountered on sonography. To determine the prevalence, cause, and significance of this finding, we examined 50 testes (25 pairs) from autopsy specimens with sonography and gross and microscopic pathology. SUBJECTS AND METHODS: Testicles were obtained at autopsy from a series of 25 male cadavers (age range, 16-80 years; mean, 62 years). Eight subjects had a history of cancer. Ex vivo sonography was performed and two board-certified radiologists graded the testis by consensus as normal, heterogeneous, or "other abnormality" (cyst, dilated rete, echogenic focus, or halo). Microscopic pathology was obtained in all abnormal (sonographic or gross pathologic) testes. The severity of tubular sclerosis (atrophy) was graded on a scale of 0-3+ by a uropathologist. RESULTS; No testicular tumors were detected. Sonography revealed normal testes in 33 specimens, heterogeneous in seven specimens, and other in 10 specimens (one cyst, two dilated rete, three halos, and seven echogenic foci). Histology revealed that all seven cases of mottled or heterogeneous testis corresponded to extensive (grades 2 and 3) regions of tubular sclerosis (atrophy). A new sonographic finding of the "halo" was attributable to a thickened, adherent tunica albuginea. CONCLUSION: The prevalence of heterogeneous testes in this elderly population was 14% and represented seminiferous tubule atrophy and sclerosis. The prevalence of clinically occult testicular cancer or metastases in this autopsy subject group was nil. Older patients with a mottled or heterogeneous testis, normal color Doppler flow, and no palpable abnormality probably do not need sonographic follow-up.     

The distinction between femoral artery pseudoaneurysms and other causes of groin masses: value of duplex Doppler sonography

With the increasing use of percutaneous transfemoral coronary angioplasty in conjunction with thrombolytic as well as anticoagulant therapy, the sonographic evaluation of groin masses, with particular emphasis on differentiating pseudoaneurysms from hematomas and other abnormalities, has become more common. Seventy-three sonograms of the groin in 60 patients (65 different groins) were reviewed retrospectively to determine the accuracy of duplex Doppler sonography in distinguishing femoral artery pseudoaneurysm (a surgical condition) from other causes of groin masses (e.g., hematomas) that are generally treated conservatively. Nineteen cases of pseudoaneurysm, 19 cases of hematoma, and 27 other conditions were studied. Of the 73 sonograms performed, 53 included duplex Doppler studies; one Doppler study was false-negative and two were possibly false-positive. The sensitivity, specificity, and accuracy of duplex Doppler sonography in the detection of femoral artery pseudoaneurysm was 95 +/- 5.8%, 94 +/- 6.4%, and 94 +/- 6.4%, respectively (95% confidence limit). We conclude that duplex Doppler sonography is of value in the differential diagnosis of groin masses.     

Real-time breast sonography: application in 300 consecutive patients

Sonography, disappointing as a primary screening method, has emerged as the single most helpful adjunct to mammography in evaluation of the clinically and/or mammographically abnormal breast. Sonography can reliably diagnose simple cysts presenting as palpable masses or as indeterminate, nonpalpable lesions on mammography. However, differentiation of benign from malignant solid masses cannot be reliably accomplished by sonography. The expense of an automated breast sonographic scanner has deterred many radiologists from the purchase of such a unit. The authors have used both an automated breast scanner and a real-time 10-MHz hand-held unit. This paper describes their experience with the real-time unit, demonstrating both normal and pathologic anatomy. Special emphasis has been placed on the sonographic diagnosis of a simple cyst because this lesion was the cause of one-quarter of all palpable masses and nonpalpable, mammographically dominant masses. Cysts are sharply marginated and anechoic. Posterior enhancement visible in 78 of 80 cysts was not demonstrable on all images in 25% of cysts.     

Grey-scale ultrasonic characteristics of carcinoma of the pancreas.

Fifty-five sonograms were performed on 25 cases of surgically and histologically proven carcinoma of the pancreas. The sonographic appearances of the tumour were determined. A diffuse echogenic pattern with irregular margin was the most common appearance. Displacement and indentation of the inferior vena cava and superior mesenteric vessels, greatly assist in localizing the tumour to the pancreas. A reliable prediction of tumour size and resectability cannot be determined by sonography alone. Sonography is helpful in assessing the response of unresectable pancreatic carcinoma to therapy. A more sonolucent appearance of the tumour occurs following chemotherapy.     

Benign non-cystic scrotal tumors and pseudotumors

There is a wide spectrum of benign, non-cystic scrotal lesions that show characteristic histo-morphology and natural history. While sonography is the preferred modality for the diagnosis of both testicular and extratesticular masses, MRI is used as a problem-solving modality when sonographic findings are inconclusive. This article reviews the cross-sectional imaging features of benign, non-cystic, intra- and extratesticular lesions. Definitive diagnosis of benign scrotal lesions may lead to conservative management including testicular preserving surgery.     

Fibrotic lesions of the testicle: sonographic patterns mimicking malignancy.

All testicular sonograms performed over a 2.5-year period were retrospectively reviewed, yielding eight patients with pathologically proven lesions consisting primarily of tubular sclerosis and interstitial fibrosis. Only two patients (25%) had a palpable abnormality. A variety of sonographic patterns was found, including focal hypoechoic or hyperechoic lesions and diffuse heterogeneity of the testicular parenchyma. The clinical and sonographic findings prompted open biopsy or orchiectomy in all cases. In the same time period, nine pathologically proven testicular malignancies were evaluated sonographically and displayed either well-defined hypoechoic or diffusely heterogeneous echo patterns. All but two of these patients (78%) had palpable abnormalities. This study demonstrates a significant overlap in the sonographic appearance of benign fibrotic lesions and testicular malignancies. When careful palpation of a sonographically heterogeneous or focal hypoechoic lesion fails to reveal a mass and serum tumor markers are negative, an open biopsy with frozen section analysis should be considered rather than proceeding directly to orchiectomy. Homogeneously hyperechoic masses can be considered benign and do not require surgery.     

Fibrotic lesions of the testicle: Sonographic patterns mimicking malignancy

All testicular sonograms performed over a 2.5-year period were retrospectively reviewed, yielding eight patients with pathologically proven lesions consisting primarily of tubular sclerosis and interstitial fibrosis. Only two patients (25%) had a palpable abnormality. A variety of sonographic patterns was found, including focal hypoechoic or hyperechoic lesions and diffuse heterogeneity of the testicular parenchyma. The clinical and sonographic findings prompted open biopsy or orchiectomy in all cases. In the same time period, nine pathologically proven testicular malignancies were evaluated sonographically and displayed either well-defined hypoechoic or diffusely heterogeneous echo patterns. All but two of these patients (78%) had palpable abnormalities. This study demonstrates a significant overlap in the sonographic appearance of benign fibrotic lesions and testicular malignancies. When careful palpation of a sonographically heterogeneous or focal hypoechoic lesion fails to reveal a mass and serum tumor markers are negative, an open biopsy with frozen section analysis should be considered rather than proceeding directly to orchiectomy. Homogeneously hyperechoic masses can be considered benign and do not require surgery.     

Dynamic sonographic evaluation of peroneal tendon subluxation

OBJECTIVE: Peroneal tendon subluxation is a major cause of posttraumatic lateral ankle pain. Because peroneal subluxation often occurs only when the foot is dorsiflexed and everted, findings on static imaging studies may appear to be normal. We therefore evaluated the effectiveness of sonography in revealing peroneal tendon subluxation in patients performing stress maneuvers. MATERIALS AND METHODS: From June 2001 to June 2003, 13 consecutive patients (10 females and three males; mean age, 30.4 years; age range, 16-66 years) in whom peroneal tendon subluxation was clinically suspected were scanned with a high-frequency linear array transducer by an experienced sonologist. The ankles in 10 asymptomatic volunteers were also scanned. Sequential axial and longitudinal sonograms of the peroneus longus and peroneus brevis tendons at rest were obtained and evaluated for tendinitis and tendon tears. Real-time axial sonograms were then obtained while the foot was dorsiflexed and everted. Of the 13 patients, 12 had sonographic findings of peroneal tendon subluxation and underwent surgical exploration. The sonographic and surgical reports of these 12 patients were compared. RESULTS: All 12 patients with sonographic findings of peroneal tendon subluxation were subsequently found to have subluxation at surgery. The positive predictive value of dynamic sonography for peroneal tendon subluxation was therefore 100%. Sonography revealed peroneus brevis tendon tears in five patients and a peroneus longus tear in one; all findings were confirmed at surgery, with no false-positive sonograms. Only four of the 20 asymptomatic ankles showed subluxation, and none had any other tendon abnormalities. CONCLUSION: Sonography is an effective technique for diagnosing peroneal tendon subluxation, as well as associated tears of the peroneal tendons.     

Acute scrotal abnormalities in children: diagnosis by combined sonography and scintigraphy

Both scintigraphy and real-time sonography have been used to assess acute symptoms involving the scrotum. However, because of its high sensitivity and ability to document physiologic abnormalities, scintigraphy has been the procedure of choice. Scintigraphy, however, lacks specificity; its value lies mainly in serving to distinguish torsion from nontorsion. The purpose of this study was to supplement scrotal scintigraphy with sonography to determine if the combination improves diagnosis and management compared with scintigraphy alone. Forty-three scrotal scintigrams and sonograms were performed on 40 consecutive patients with acute scrotal symptoms. The interpretation of the scintigram was altered by sonography in six (14%) of the combined scans, directly affecting clinical management. In three patients with acute hydroceles diagnosed by sonography, exploratory surgery was avoided despite scintigraphic findings suggesting testicular torsion. Scintigraphy was normal in two patients with spontaneous testicular detorsion, whereas sonography showed recent spermatic-cord torsion that required subsequent orchiopexy. In a patient with epididymitis and orchitis, sonography showed a complicating scrotal abscess, which was not apparent on scintigraphy and which required antibiotic treatment. The addition of sonography to the scintigraphic evaluations of children with acute scrotal abnormalities changed the diagnosis and clinical management in 14% of the patients studied.     

Sonography of the painful hip in children: 500 consecutive cases

Five hundred children with a painful hip or a limp were evaluated prospectively by plain films and sonography. The clinical, radiographic, and sonographic findings were correlated with the final diagnoses. Sonography disclosed hip effusion in 235 patients, and plain films were abnormal in 58 of these 235 patients and in four others. Both sonography and plain films were normal in 261 patients. No sonographic signs served to differentiate sterile, purulent, or hemorrhagic effusion. Follow-up sonograms were performed in 202 patients. Sonography showed that 73% of patients with presumed transient synovitis had no effusion 2 weeks after diagnosis. Patients with hip disorders other than transient synovitis had persistent effusion for more than 2 weeks; however, that was also observed in 27% of patients with presumed transient synovitis. Sonography was more sensitive than plain films for detecting hip effusion. However, sonographic detection of effusion changed the therapeutic approach in only six patients.     

Anorectal atresia: prenatal sonographic diagnosis

To determine the prenatal sonographic findings of anorectal atresia (ARA), we retrospectively reviewed 12 proven cases. Sonography showed abnormally dilated bowel segments in five cases (42%), four of which were identified prospectively; at autopsy, two other cases showed mild colon dilatation not evident on sonograms. Bowel dilatation was not associated with the location of atresia or the presence of a fistula, but was possibly related to menstrual age. Eleven fetuses (92%) had significant other anomalies primarily related to the VACTERL syndrome (vertebral defects, anal atresia, tracheoesophageal fistula with esophageal atresia, radial and renal dysplasia, and limb malformations) and/or the caudal regression syndrome; of these, sonography identified one or more concurrent anomalies in seven cases. In two cases, bowel dilatation was the primary sonographic finding. Death in nine cases resulted from termination of pregnancy (four cases) or perinatal demise (five cases); three patients are still alive. We conclude that some cases of ARA can be suspected on prenatal sonograms by demonstration of dilated colon, and that the sensitivity of this finding may be related to menstrual age at the time of the examination. Distinguishing ARA from other causes of fetal-bowel dilatation is important because of the frequency of concurrent anomalies associated with ARA.     

Sonography of the pediatric scrotum: emphasis on the Ts--torsion, trauma, and tumors

OBJECTIVE: The purpose of this article is to review the different scrotal disease entities in the pediatric population, focusing on acute scrotum, traumatic injuries, and testicular tumors. CONCLUSION: Many pediatric scrotal disorders can be well characterized on sonography. An understanding of the various disease entities, their clinical presentations, and the typical sonographic features should all be combined to make an accurate diagnosis.