Contrast‐Enhanced Breast Ultrasonography

Objective. The purpose of this study was to identify histopathologic correlates for the varied appearances of breast masses on contrast‐enhanced ultrasonography (CEUS). Methods. Contrast‐enhanced ultrasonography was performed in 104 patients (age range, 19–86 years) after administration of a sulfur hexafluoride microbubble contrast agent, and enhancement patterns were classified as no enhancement, peripheral enhancement, homogeneous enhancement, regional enhancement, and heterogeneous enhancement. All patients' histologic slides were reviewed and correlated with CEUS findings. Results. In malignant masses, heterogeneous enhancement corresponded to tumor cell cords or clusters in a variable amount of desmoplastic stroma. Homogeneous enhancement corresponded to hypercellularity in the whole mass, or ductal carcinoma in situ (DCIS) was predominant. Regional enhancement corresponded to a DCIS component. Peripheral enhancement corresponded to a DCIS component, hypercellularity or adenosis at the periphery, and low‐degree cellularity, degeneration, fibrosis, or necrosis in the center. No enhancement was present in 1 case of low‐grade DCIS. In benign masses, heterogeneous enhancement corresponded to loose cell proliferation in a more sclerotic stroma. Homogeneous enhancement corresponded to diffuse hypercellularity, an inflammatory cell infiltrate, or intraductal papilloma. Regional enhancement corresponded to focal hypercellularity or intraductal papilloma within a dilated duct. No enhancement corresponded to desmoplastic stroma. Peripheral enhancement was shown in 1 case of granulomatous mastitis with an inflammatory infiltrate at the periphery and necrosis in the center. Conclusions. Breast mass CEUS findings correlated with histologic features.     

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.     

What Does 2‐Dimensional Imaging Add to 3‐ and 4‐Dimensional Obstetric Ultrasonography?

OBJECTIVE: The purpose of this study was to determine whether 2-dimensional (2D) ultrasonography adds diagnostic information to that provided by the examination of 3-dimensional/4-dimensional (3D/4D) volume data sets alone. METHODS: Ninety-nine fetuses were examined by 3D/4D volume ultrasonography. Volume data sets were evaluated by a blinded independent examiner who, after establishing an initial diagnostic impression by 3D/4D ultrasonography, performed a 2D ultrasonographic examination. The frequency of agreement and diagnostic accuracy of each modality to detect congenital anomalies were calculated and compared. RESULTS: Fifty-four fetuses with no abnormalities and 45 fetuses with 82 anomalies diagnosed by 2D ultrasonography were examined. Agreement between 3D/4D and 2D ultrasonography occurred for 90.4% of the findings (123/136; intraclass correlation coefficient, 0.834; 95% confidence interval, 0.774-0.879). Six anomalies were missed by 3D/4D ultrasonography when compared to 2D ultrasonography (ventricular septal defect [n = 2], interrupted inferior vena cava with azygous continuation [n = 1], tetralogy of Fallot [n = 1], horseshoe kidney [n = 1], and cystic adenomatoid malformation [n = 1]). There were 2 discordant diagnoses: transposition of the great arteries diagnosed as a double-outlet right ventricle and pulmonary atresia misinterpreted as tricuspid atresia on 3D/4D ultrasonography. One case of occult spinal dysraphism was suspected on 3D ultrasonography but not confirmed by 2D ultrasonography. When compared to diagnoses performed after delivery (n = 106), the sensitivity and specificity of 3D/4D ultrasonography (92.2% [47/51] and 76.4% [42/55], respectively) and 2D ultrasonography (96.1% [49/51] and 72.7% [40/55]) were not significantly different (P = .233). CONCLUSIONS: Information provided by 2D ultrasonography is consistent, in most cases, with information provided by the examination of 3D/4D volume data sets alone.     

Role of Contrast‐Enhanced Ultrasonography in Primary Hepatic Lymphoma

Objective. Ultrasonography is the first examination performed for screening of hepatocellular carcinoma (HCC); contrast‐enhanced ultrasonography (CEUS) can help discriminate between HCC and other lesions. Primary hepatic lymphoma (PHL), even if rare, should be considered in the differential diagnosis of focal liver lesions (FLLs). Few data are available in the literature about the role of CEUS in the diagnosis of PHL; we tried to determine whether CEUS could have a role in this setting. Methods. we describe 2 cases of primary non‐Hodgkin lymphoma of the liver associated with hepatitis B virus (HBV) infection. The first patient was a 62‐year‐old man who was an HBV‐inactive carrier, and the second was a 58‐year‐old man with type 2 diabetes and chronic HBV hepatitis. Results. in both cases, ultrasonography showed a hypoechoic liver lesion (4 and 3 cm, respectively) with irregular margins in segment 4 of the liver. On CEUS, these lesions were inhomogeneously hyperenhanced in the arterial phase and hypoenhanced in the portal and late phases. Contrast‐enhanced computed tomography (CT) in both patients showed slight hyperenhancement in the arterial phase and hypoenhancement in the remaining phases. Needle biopsy showed marginal zone B‐cell lymphoma of the mucosa‐associated lymphoid tissue type in both patients. Conclusions. Contrast‐enhanced ultrasonography and CT did not help us differentiate PHL from HCC; in fact, in both cases we saw the characteristic findings of primary HCC. Primary hepatic lymphoma is a rare condition, but it should always be considered in the differential diagnosis of FLLs. We stress the important role of liver biopsy when imaging indicates HCC in patients without underlying cirrhosis.     

Behavior of Hepatocellular Adenoma on Real‐time Low‐Mechanical Index Contrast‐Enhanced Ultrasonography With a Second‐Generation Contrast Agent

Objective. The purpose of this study was to describe the behavior of histologically proven hepatocellular adenoma (HCA) on low‐mechanical index (MI) contrast‐enhanced ultrasonography (CEUS). Methods. A review of the databases from 4 academic hospitals revealed 18 patients (15 female and 3 male; mean age, 40 years; range, 25–71 years) with 25 histologically proven HCA lesions who were studied with CEUS at a low MI (0.04–0.1). Results. Twenty‐four of 25 lesions (96%; 95% confidence interval [CI], 80.5%–99.3%) showed high‐intensity enhancement, scored as 3 on a scale of 0 to 3, whereas only 1 lesion (4%; 95% CI, 0.7%–19.5%) was scored as 2. The time of peak enhancement ranged between 10 and 19 seconds (average, 13 seconds). All but 1 of the 25 lesions (96%; 95% CI, 80.5%–99.3%) showed early homogeneous and centripetal enhancement during the hepatic arterial phase. No portal venous phase enhancement was observed in any lesion because all showed rapid wash‐out (100%; 95% CI, 86.7%–100%). Twenty lesions (80%; 95% CI, 60.9%–91.1%) were found to be isoechoic to slightly hypoechoic during the portal phase, and 19 (76%; 95% CI, 56.6%–88.5%) were isoechoic to mildly hypoechoic, whereas 7 (24%; 95% CI, 11.5%–43.4%) were hypoechoic during the late phase. Conclusions. Contrast‐enhanced ultrasonography is an effective technique for identifying the microvascular and macrovascular characteristics of HCA. Typically, HCA shows early (10–19 seconds) and centripetal enhancement during the arterial phase and isoechogenicity or mild hypoechogenicity during the portal phase, remaining slightly hypoechoic or isoechoic during the late phase in most cases.     

Clinical Application of Contrast‐Enhanced Ultrasonography in Diagnosis of Superficial Lymphadenopathy

Objective. The purpose of this study was to evaluate the value of contrast‐enhanced ultrasonography (CEUS) in differential diagnosis of superficial lymphadenopathy. Methods. Ninety‐four superficial enlarged lymph nodes in 94 patients were studied by conventional ultrasonography (gray scale and color Doppler) and CEUS. Contrast‐enhanced sonograms were analyzed using contrast‐specific quantification software. All of the results were compared with pathologic diagnoses. Results. Of the 94 lymph nodes examined, 44 were benign and 50 were malignant (33 metastases and 17 lymphomas). The sensitivity, specificity, and accuracy of conventional ultrasonography in differential diagnosis between benign and malignant nodes were 51%, 47%, and 55%, respectively. Contrast‐enhanced ultrasonography showed intense homogeneous enhancement in 39 of 44 benign lymph nodes, inhomogeneous enhancement in 32 of 33 metastases, and intense homogeneous enhancement and absence of perfusion in 9 of 17 and 6 of 17 lymphomas, respectively. The sensitivity specificity, and accuracy of CEUS were 84%, 79%, and 80%. After time‐intensity curve gamma variates were calculated, the area under the curve of the benign lymph nodes was greater than those of the metastatic lymph nodes and lymphomas (P < .01). Conclusions. These results indicate that the use of CEUS and contrast‐specific software has a higher degree of diagnostic accuracy than conventional ultrasonography for evaluations of superficial lymphadenopathy. The contrast enhancement patterns and time‐intensity curves provide valuable diagnostic information for differential diagnosis of benign and malignant lymph nodes.     

Abnormal Number of Fetal Ribs on 3‐Dimensional Ultrasonography

Objective. The purpose of this study was to describe the clinical importance of an abnormal number of fetal ribs. Methods. A retrospective study of all fetuses that were found to have an abnormal number of ribs during routine ultrasonographic examinations was performed. Volume data sets of the fetal ribs were acquired by either static 3‐ or 4‐dimensional volume contrast imaging in plane C. In all cases, a meticulous survey of the fetal anatomy was performed, and prenatal and postnatal records were reviewed. Results. Seventy‐five fetuses were found retrospectively to have an abnormal number of ribs. Ultrasonographic examinations were done between 14 and 31 weeks' gestation (mean, 21.8 weeks; median, 23 weeks). More than 24 ribs were found in 28 fetuses (37%), and fewer than 24 ribs were found in 47 (63%). Additional anomalies were found in 22 fetuses (29%). Cardiovascular anomalies were detected in 10 fetuses. Seven fetuses had renal anomalies. Two fetuses had mild ventriculomegaly, and 1 fetus had holoprosencephaly. Lung dysplasia was found in 2 cases. One fetus had enlarged nuchal translucency with wormian bones. Termination of pregnancy was performed in 3 cases because of major malformations. The other 19 fetuses with associated abnormalities and the 53 without associated anomalies were born alive with only minor anomalies. Conclusions. An abnormal number of fetal ribs is an isolated finding in most cases. It may also be seen with major anomalies; however, more frequently the anomalies are minor, and the overall prognosis is good.     

Value of Contrast‐Enhanced Ultrasonography in Assessing the Vascularity of Liver Metastases

Objective. The purpose of this study was to compare the capability of contrast‐enhanced ultrasonog‐raphy (CEUS) and contrast‐enhanced computed tomography (CECT) in evaluating the vascularity of liver metastases. Methods. Both CEUS and CECT examinations were performed on 70 patients with liver metastases, which were from colon carcinoma in 31, rectal carcinoma in 17, pancreatic carcinoma in 5, and others in 17. In patients with multiple lesions, the most easily observed lesion was selected as the target lesion for evaluation of vascularity. Results. Peak enhancement of the target lesion during the arterial phase was characterized as hyperenhancement, isoenhancement, hypo‐enhancement, and nonenhancement in 61 (87.1%), 6 (8.6%), 3 (4.3%), and 0 (0%) patients on CEUS, respectively, and in 52 (74.3%), 8 (11.4%), 8 (11.4%), and 2 (2.9%) on CECT. Contrast‐enhanced ultrasonography showed more lesions with hyperenhancement than CECT (P < .01). The enhancement pattern during the arterial phase was homogeneous, inhomogeneous, and rimlike in 30 (42.9%), 16 (22.9%), and 24 (34.2%) patients on CEUS and in 13 (18.6%), 8 (11.4%), and 49 (70%) on CECT. Contrast‐enhanced ultrasonography revealed more lesions with homogeneous enhancement than CECT (P < .01). Contrast‐enhanced ultrasonography showed dysmorphic vessels in 33 patients (47.1%) during the arterial phase, whereas CECT showed dysmorphic vessels in 27 (38.6%; P < .01). Contrast‐enhanced ultrasonography showed hypervascular lesions in 58.6% of patients, whereas CECT showed hypervascular lesions in 12.9% (P < .01). Conclusions. Contrast‐enhanced ultrasonography was superior to CECT in assessing the vascularity of liver metastases.     

A Method for Assessing the Microvasculature in a Murine Tumor Model Using Contrast‐Enhanced Ultrasonography

Objective. The purpose of this study was to develop a method for assessing tumor vascularity in a preclinical model of breast cancer using contrast‐enhanced ultrasonography. Methods. Eight mice were injected with 67NR breast cancer cells on their hind limbs and imaged with ultrasonography 8 days later. Mice were injected with an ultrasound contrast agent (UCA), and a sequence of images of the resultant backscattered echoes was recorded before and after high‐power “destruction” pulses for each of multiple parallel planes. From these, data maps of the maximum contrast enhancement (within each time course) were constructed for each pixel, which enabled reconstruction of high‐resolution coregistered sections into a 3‐dimensional (3D) volume reflecting tumor vascularity. Additional studies were performed to determine the duration and repeatability of image enhancement, and images were correlated with conventional 3D power Doppler measurements. Results. The lifetime of the UCA in vivo was found to be 4.3 ± 1.09 minutes (mean ± SD). The 3D contrast‐enhanced ultrasonographic technique produced images that correlated well with power Doppler images in specific regions but also depicted additional regions of flow surrounding the power Doppler signal. The mean correlation coefficient between voxel measurements of the central slice for each animal was 0.64 ± 0.07 (P < .01). In addition, sequential studies in each animal were reproducible. Conclusions. A method producing high‐resolution volumetric assessments of tumor vascularity in a preclinical model of breast cancer is shown that correlates with other ultrasonographic measures of blood flow, which may provide greater sensitivity to the microvasculature.     

Intrapartum Measurement of Cervical Dilatation Using Translabial 3‐Dimensional Ultrasonography

Objective. The purpose of this study was to determine the accuracy and reproducibility of intrapartum translabial 3‐dimensional (3D) ultrasonographic measurements of cervical dilatation during labor. Methods. A prospective observational study was conducted. Three‐dimensional ultrasonographic volume data sets from 52 patients were collected during labor and stored. Later, all volumes were randomly reviewed twice offline by 2 examiners blinded to previous clinical and ultrasonographic measurements. The correlation with delivery room personnel digital vaginal examinations and interobserver and intraobserver agreement were determined. Results. Twenty‐four patients were examined during the latent phase (0‐ to 4‐cm cervical dilatation), and 28 patients were examined during the active phase (5‐ to 10‐cm cervical dilatation). Translabial 3D ultrasonographic measurements of the cervical mean and maximal diameters and inner cervical area showed a positive correlation with digital vaginal examinations (r² = 0.609, 0.587, and 0.469, respectively; all P < .001). The interobserver mean differences ± SD between paired measurements for the mean and maximal cervical dilatation and inner cervical area were 0.11 ± 0.49 cm, 0.12 ± 0.48 cm, and ?0.22 ± 5.69 cm², and the intraclass correlation coefficients (ICCs) were 0.82, 0.85, and 0.87. The intraobserver mean differences between paired measurements of the mean and maximal cervical dilatation and inner cervical area were 0.002 ± 1.15 cm, 0.02 ± 1.4 cm, and ?0.41 ± 1.15 cm², and the ICCs were 0.85, 0.79, and 0.75. Conclusions. Assessment of cervical dilatation using 3D ultrasonography during labor is feasible and reproducible.     

Application of 3‐Dimensional Ultrasonography to Imaging the Fetal Anal Canal

Objective. Ultrasonography has been applied previously to the assessment of the fetal anal canal. We aimed to examine the potential of 3‐dimensional ultrasonography (3DUS) in the evaluation of the fetal anal canal and to obtain normal fetal anal canal measurements. Methods. Patients were recruited from an unselected population of gravidas with known gestational age (by dates or first‐trimester ultrasonography) and without known fetal anomalies presenting for fetal evaluation in the ultrasound units of 2 tertiary care centers between 16 and 39 gestational weeks. In addition to the ordered scan, 3DUS imaging of the fetal anal canal was performed. Transverse and sagittal views and volumes were obtained. Measurements of the fetal anal canal anteroposterior diameter, lateral diameter, and length were performed in transverse and sagittal planes, respectively, and scatterplots of these dimensions were created. Measurements were performed and repeated on raw data sets by 2 independent observers, and the results were analyzed to estimate interobserver and intraobserver reliability. Results. A total of 186 patients were examined for this study at 16 to 39 weeks' gestation (mean, 27.4 weeks). The anteroposterior diameter of the fetal anal canal in this study group ranged from 4 to 21 mm (mean, 11.2 mm; SD, ±3.5 mm), whereas the lateral diameter ranged from 7 to 18 mm (mean, 9.1 mm; SD, ±3.0 mm). The length of the fetal anal canal in this study group ranged from 3 to 24 mm (mean, 14.3 mm; SD, ±3.8 mm). Conclusions. Ultrasonographic assessment of the fetal anal canal with 3DUS is feasible. Scatterplots were created for internal anal sphincter width and length measurements from 16 to 39 weeks' gestation. Larger studies are necessary to establish nomograms of these measurements and their application to the evaluation of pathologic cases. We speculate that 3DUS assessment of the fetal anal canal may improve detection rates of disorders involving this system.