Sonography of lymphangioleiomyoma in lymphangioleiomyomatosis: demonstration of diurnal variation in lesion size

OBJECTIVE: Our aims were to define the sonographic features of abdominal and pelvic lymphangioleiomyomas in lymphangioleiomyomatosis (LAM) and to evaluate the utility of sonography in visualizing diurnal change in the size of the masses. MATERIALS AND METHODS: Forty-four patients with LAM and abdominal and pelvic lymphangioleiomyomas found on screening CT underwent sonography. Twenty-two patients had two studies on the same day, one in the morning and the other late in the afternoon. RESULTS: Forty-nine masses were scanned in the 44 patients. The anatomic distribution of the masses was the following: retroperitoneal (29/44 patients, 66%), pelvic (10/44, 23%), and both retroperitoneal and pelvic (5/44, 11%). Of the 49 masses, 12 (24%) were cystic, 16 (33%) were solid, and 21 (43%) were complex. Twenty-two patients underwent sonography in the morning and afternoon. The masses increased in size between the two studies in all 21 patients in whom the masses were visualized in both studies. In three of 21 patients, the echotexture of the masses changed between the morning and afternoon studies: In two the echotexture changed from solid to complex, and in the other, it changed from hyperechoic to isoechoic relative to the liver. CONCLUSION: The sonographic characteristics of lymphangioleiomyomas are similar to some neoplasms such as lymphoma and ovarian cancer (a similarity that sometimes prompts biopsy). After a mass is shown in a patient with LAM, repeat sonography in the morning and afternoon is useful to depict diurnal variation in size and echotexture and to confirm the diagnosis of lymphangioleiomyoma and avoid biopsy.     

The value of MR imaging in distinguishing leiomyomas from other solid pelvic masses when sonography is indeterminate

The differentiation of a uterine leiomyoma from other solid pelvic masses on sonography is usually straightforward. Occasionally, the sonographic appearance of a pedunculated uterine leiomyoma may simulate that of a solid adnexal mass. The purpose of this study was to determine if MR imaging adds specificity to the diagnosis of indeterminate solid pelvic masses visualized with sonography. Nineteen patients were imaged with MR after sonography revealed the presence of a solid pelvic mass adjacent to the uterus but could not be used to determine whether the mass was a leiomyoma or some other type of tumor. The diagnostic criteria for a leiomyoma on MR imaging included (1) the presence of a mass adjacent to the uterus and (2) a mass that was predominantly low signal intensity or isointense compared with normal myometrium on T1-weighted images and predominantly low signal intensity on T2-weighted images. In 11 of 13 patients, the masses that met these MR criteria for leiomyoma were proved to be uterine leiomyomas at surgery. Another mass that met the criteria was shown to be a leiomyoma in the broad ligament; the other was an ovarian fibroma. Of the six cases that did not meet the MR criteria for the diagnosis of leiomyoma, three were proved to be degenerated fibroids, one was squamous cell carcinoma of the cervix, and two were ovarian malignant tumors. Because leiomyomas often have an MR appearance that is distinct from that of solid pelvic malignant tumors, MR imaging can be useful for the diagnosis of some indeterminate solid pelvic masses.     

Infiltrating lobular carcinoma: mammographic patterns with pathologic correlation

Of the five identified radiographic patterns of ILC, the most common was a poorly defined asymmetric density with architectural distortion. Areas of ILC frequently are of low density, not much greater than that of the surrounding parenchyma. The mammographic appearance may reflect the behavior of ILC tumor cells, which travel in linear array ("single file") along and around the arborizing ducts that serve as scaffolding for these small, malignant cells that permeate the parenchyma without a central nidus. This feature of ILC may also help explain why tumors may be palpable as areas of vague induration or thickening rather than as discrete masses. When tumors are hidden in dense breast tissue (pattern 3) and not well imaged by mammography or when there are subtle mammographic changes (pattern 1), sonography may help confirm the presence of a solid mass. Most of the suspected tumors imaged by sonography were palpable as discrete masses or areas of induration.     

Spermatic cord sarcomas: sonographic and CT features

Five patients with sarcomas of the spermatic cord were imaged with sonography and/or computed tomography (CT). The former modality is most helpful in demonstrating the extratesticular origin of the mass and evaluating its scrotal extension for local staging. CT is necessary for pelvic staging and searching for distant metastasis. The fat in liposarcomas was easily identified by CT, although it was not echogenic on sonography. Sonography should be the primary imaging modality for scrotal or inguinal masses. If a neoplasm is found, CT should be used for staging, prior to definitive surgical treatment.     

Spermatic cord sarcomas: Sonographic and CT features

Five patients with sarcomas of the spermatic cord were imaged with sonography and/or computed tomography (CT). The former modality is most helpful in demonstrating the extratesticular origin of the mass and evaluating its scrotal extension for local staging. CT is necessary for pelvic staging and searching for distant metastasis. The fat in liposarcomas was easily identified by CT, although it was not echogenic on sonography. Sonography should be the primary imaging modality for scrotal or inguinal masses. If a neoplasm is found, CT should be used for staging, prior to definitive surgical treatment.     

Transvaginal sonography: comparison with transabdominal sonography in the diagnosis of pelvic masses

In a retrospective study, we compared transvaginal sonograms with transabdominal sonograms in 67 women referred for evaluation of palpable pelvic masses. The diagnoses included ovarian cyst (27), endometrioma (12), complex cyst (four), dermoid (three), infection (three), ovarian malignancy (two), and uterine fibroid (three). The final diagnosis was made surgically in 41 patients (61%) and by a combination of sonographic and clinical correlation in the remaining patients. More information about the internal architecture or anatomy of the mass was provided by the transvaginal images than by the transabdominal scans in 51 (76%) of the patients. Transabdominal sonography did not provide more diagnostic information in any of the patients examined. Transvaginal sonography was helpful in obese patients, in those with a large amount of bowel gas, and in those unable to achieve adequate bladder filling. Six simple cysts and four complex pelvic masses were identified solely on transvaginal sonograms. The results suggest that transvaginal sonography has considerable advantages over conventional transabdominal sonography in the evaluation of pelvic masses in women.     

US-guided biopsy of neck masses in postoperative management of patients with thyroid cancer

High-frequency (10-MHz) sonography demonstrated a cervical mass or lymphadenopathy, or both, during postoperative follow-up of 52 patients who had undergone surgery for thyroid cancer. Percutaneous biopsy with ultrasonographic (US) guidance was performed in all 52 masses, 44 of which were nonpalpable. Malignant cells were obtained in 29 biopsies, and the results of 20 biopsies were negative, yielding benign lymphocytes only. Results in three biopsies were nondiagnostic due to hypocellular specimens. Therefore, 94% of biopsy results (49) of 52) were confidently assigned as either positive (56%) or negative (38%) for malignancy. There were no complications. High-frequency sonography can demonstrate clinically occult thyroid bed tumor recurrence and lymph node metastases. US-guided biopsy is an accurate and safe technique to confirm or exclude malignancy in patients at high risk of recurrence of thyroid cancer.     

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.     

Gray-scale ultrasound in tubal pregnancy

Sonographic signs were correlated with clinical data, surgical findings, and pathology in 15 patients withtubal pregnancy. Sonograms showed absence of intrauterine gestation in 12 patients. In 3, structures resembling gestational sacs were produced by decidual reaction and blood in the uterine cavity separating the endometrial echoes. The uterus was normal in size in 6 cases. Almost all sonograms showed a pelvic mass (usually adnexal) displacing the uterus. Seven patients had predominantly sonolucent masses, 3 had complex masses, and 4 had both types. Only one woman exhibited a definite gestational sac in an extrauterine location. Four patients had a negative pregnancy test at the time of sonography. Meticulous sonographic technique and a high index of suspicion will facilitate the diagnosis of tubal pregnancy in most cases.     

Ectopic pregnancy: Value of transabdominal sonography without deliberate bladder distention

We reviewed 19 consecutive patients with ectopic pregnancy in whom pelvic sonography demonstrated findings highly predictive of the diagnosis. The correct diagnosis was established by transabdominal sonography without attempting bladder distention in 12 patients (63%); the bladder was full in only one patient. Transabdominal sonography performed without waiting for the bladder to fill and thus with no delay or patient discomfort can establish the presence of ectopic pregnancy and obviate the need for transvaginal sonography in a substantial proportion of patients in whom the diagnosis can be made sonographically. In patients at risk for ectopic pregnancy, we recommend that transabdominal sonography without waiting for bladder distention be attempted before transvaginal sonography is performed.     

灰阶超声与X线诊断乳腺良性病变的比较分析

本文分析了65例经手术病理证实的乳腺良性病变的灰阶超声及X线表现，并对比后两者诊断结果。65例中X线诊断正确29例，正确率44％，超声诊断正确40例，正确率61％，9例致密型乳腺X线片未见肿块，经B超检查均诊断正确，因此我们认为，年青患者或X线显示致密型乳腺者，利用超声检查很有帮助，尤其在鉴别囊，实性和实性肿块方面准确率高，而中老年患者可先行X线检查，如诊断明确者，可不必再行B超检查。     

Diagnosis of ectopic pregnancy: endovaginal vs transabdominal sonography

During a 25-month period, 193 women with the clinical diagnosis of suspected ectopic pregnancy had transabdominal and endovaginal sonograms. Most had quantitative determinations of serum human chorionic gonadotropin (HCG). Endovaginal sonography was diagnostic of ectopic pregnancy in 23 (38%) of the 60 patients with surgically proved ectopic pregnancies: transabdominal sonography was diagnostic in 13 patients (22%). All 83 intrauterine pregnancies were identified with endovaginal sonography, compared with 34 identified with transabdominal sonography. Endovaginal sonography was somewhat more helpful in the diagnosis of missed abortion and blighted ovum. Eighty endovaginal sonograms were classified as indeterminate as compared with 141 transabdominal studies. This indeterminate group included patients with complete abortions, ectopic pregnancies without sonographic evidence of an extrauterine gestation, incomplete abortions, and patients with subsequent negative serum levels. As in prior reports, endovaginal sonography was superior to transabdominal sonography in the evaluation of suspected ectopic pregnancies. Overall, endovaginal sonography was diagnostic in 113 patients, whereas transabdominal sonography was diagnostic in 52 patients. The finding of an extrauterine fetal pole or embryo was diagnostic for an ectopic pregnancy. Pelvic fluid, the appearance of the endometrium, and a single positive serum HCG determination were not helpful in making the diagnosis of ectopic pregnancy.     

Pictorial essay: Transabdominal and endovaginal sonography of adnexal masses

Endovaginal sonography is rapidly becoming the diagnostic procedure of choice when evaluating patients with early pregnancy and assessing uterine abnormalities. However, there has been relatively little discussion of endovaginal sonography in the evaluation of adnexal masses. Using endovaginal sonography we studied 50 patients with clinically suspected adnexal masses, in whom transabdominal sonography was either suboptimal or failed to adequately characterize the mass. The purpose of this pictorial essay is to depict the normal anatomy of the ovaries and adnexa and highlight the unique contribution of endovaginal sonography in diagnosing a variety of adnexal masses, including tubal and ovarian lesions.     

Comparison of IV contrast-enhanced sonography and histopathology of pancreatic cancer

OBJECTIVE: We compared contrast-enhanced sonography findings with pathologic findings in pancreatic cancer to evaluate the ability of contrast-enhanced sonography to depict the pathologic changes associated with pancreatic cancer. SUBJECTS AND METHODS: Thirty-four patients with pancreatic cancer who underwent surgery were investigated. Sonography was performed with contrast material (Levovist) for all patients before surgery. Pathologic findings were evaluated on the basis of the resected cancer specimens. We compared contrast-enhanced sonography findings with pathologic findings. RESULTS: All tumors that were hyperechoic on contrast-enhanced sonography were papillary adenocarcinoma, and all tumors that were hypoechoic on contrast-enhanced sonography were ductal adenocarcinoma. Among ductal adenocarcinomas, five (71.4%) of seven tumors for which the size of the hypoechoic area was unchanged on contrast-enhanced sonography had clear tumor margins with no infiltration or inflammation in the margin. In contrast, all tumors for which the size of the hypoechoic area was reduced on contrast-enhanced sonography had unclear tumor margins with infiltration of cancerous cells and inflammation. Nine (90%) of 10 tumors that showed partial contrast enhancement or a vascular shadow in a hypoechoic area had large or medium-sized vessels within a tumor at pathology. In contrast, only one (4.8%) of 21 tumors that did not show the vascular shadow in a hypoechoic area had no large or medium-sized vessels in a tumor. CONCLUSION: Contrast-enhanced sonography well reflects the pathologic changes of pancreatic cancer and will provide useful information in a pretreatment evaluation. Further studies with a large number of patients will be required to confirm this finding.     

Mediastinal tumors: evaluation with suprasternal sonography

Twelve patients with mediastinal masses evaluated by computed tomography (CT) and histologically verified were evaluated sonographically by means of the suprasternal approach. Eleven of 12 mediastinal tumors could be visualized sonographically, mainly as hypoechoic and perivascularly situated masses, and could be located topographically with a fair degree of certainty. Suprasternal sonography is particularly useful in the detection of small, perivascular lymphomas of the supraaortic branches. In patients with problematic CT findings, particularly children and patients with allergies to contrast media, suprasternal sonography can provide important additional information. Moreover, suprasternal sonography can be used to determine the consistency and to monitor the treatment of mediastinal tumors. Finally, the suprasternal approach is suitable for sonographically guided biopsies of mediastinal tumors.     

Imaging of Soft Tissue Tumors in the Pediatric Patient

The presence of a soft tissue mass in children is of concern to parents and physicians. Fortunately, these masses are rare and usually benign or pseudotumoral. When dealing with malignant soft tissue tumors, therapeutic options and long-term survival are strongly related to the disease stage at the time of diagnosis. Therefore, when children present with indeterminate or persisting symptoms and posttraumatic, metabolic, or infectious disorders have been ruled out, one should perform dedicated imaging studies (conventional radiography, computed tomography [CT], or both; sonography; magnetic resonance [MR] imaging) to exclude the possibility of a nonpalpable soft tissue mass or to characterize the mass when present. An overview of the use of the different imaging modalities for evaluating soft tissue tumors in the pediatric patient is presented. Because of the numerous benign, malignant, and pseudotumoral soft tissue masses that are often encountered in children, clinical, histologic, and imaging features are presented as concise tables.     

Benign hemorrhagic adrenocortical macrocysts in Beckwith-Wiedemann syndrome

A new pseudotumorous lesion found in the adrenal cortex of six infants with Beckwith-Wiedemann syndrome is described. These cystic masses were discovered either prenatally by using sonography or early in the neonatal period as palpable flank masses. Imaging studies, including sonography and CT, could not confidently exclude malignancy. After the masses were removed surgically, histologic examination showed them all to be benign hemorrhagic macrocysts within the capsule or permanent cortex (in contrast to neonatal adrenal hemorrhage, which usually occurs more centrally in the fetal cortex). The cysts were as large as 8 cm in diameter, and in one case a solitary cyst was predominant. Hemihypertrophy was present in all cases. Four of the six lesions were right-sided, and there was a male-female ratio of 5:1. Benign hemorrhagic adrenocortical macrocysts are a cause of abdominal mass in the fetus and neonate with Beckwith-Wiedemann syndrome.     

Cost effectiveness of pelvic sonogram in the emergency room: Endovaginal vs. transabdominal examination

Ultrasound evaluation of the female pelvis is a valuable tool to diagnose pelvic pathology accurately and rapidly in the emergency room patient. Institutions differ concerning which imaging approach—transabdominal or endovaginal sonography—should be performed first, and when it is appropriate to continue to the other modality. The aim of this randomized and prospective study was to determine the most cost-effective imaging approach to pelvic sonography, without sacrificing diagnostic yield. The results of 120 patient encounters utilizing both imaging methods were as follows. Our study showed that 74% of examinations first performed transabdominally required additional endovaginal evaluation, whereas only 9% of initial examinations by endovaginal sonography required transabdominal examination. Thus, we demonstrated that the total time and expenditure of imaging decreased while we maintained high diagnostic accuracy. We recommend that all female emergency patients being evaluated for pelvic pathology, except those with a palpable pelvic mass or with a bladder that is already full, or those in the second or third trimester or pregnancy, undergo imaging initially by endovaginal sonography and that transabdominal evaluation be used as a complementary examination.     

Imaging-guided radiofrequency ablation of solid renal tumors

OBJECTIVE: We performed a retrospective review of imaging-guided radiofrequency ablation of solid renal tumors. MATERIALS AND METHODS: Since May 2000, 35 tumors in 20 patients have been treated with radiofrequency ablation. The size range of treated tumors was 0.9-3.6 cm (mean, 1.7 cm). Reasons for patient referrals were a prior partial or total nephrectomy (nine patients), a comorbidity excluding nephrectomy or partial nephrectomy (10 patients), or a treatment alterative to nephron-sparing surgery (one patient who refused surgery). Tumors were classified as exophytic, intraparenchymal, or central. Sixteen patients had 31 lesions that showed serial growth on CT or MR imaging. Of these 16 patients, four patients with 10 lesions had a history of renal cell carcinoma, and two patients with 11 lesions had a history of von Hippel-Lindau disease. Four patients had incidental solid masses, two of which were biopsied and shown to represent renal cell carcinoma, and the remaining two masses were presumed malignant on the basis of imaging features. Successful ablation was regarded as any lesion showing less than 10 H of contrast enhancement on CT or no qualitative evidence of enhancement after IV gadolinium contrast-enhanced MR imaging. RESULTS: Of the 35 tumors, 22 were exophytic and 13 were intraparenchymal. Twenty-seven of the 35 were treated percutaneously using either sonography (n = 22) or CT (n = 5). Two patients had eight tumors treated intraoperatively using sonography. Patients were followed up with contrast-enhanced CT (n = 18), MR imaging (n = 5), or both (n = 5) with a follow-up range of 1-23 months (mean, 9 months). No residual or recurrent tumor and no major side effects were seen. CONCLUSION: Preliminary results with radiofrequency ablation of exophytic and intraparenchymal renal tumors are promising. Radiofrequency ablation is not associated with significant side effects. Further follow-up is necessary to determine the long-term efficacy of radiofrequency ablation.     

Sonographic demonstration of buckling of the great vessels of the neck

Clinical, sonographic, and radiographic features in 11 patients with pulsatile neck masses due to buckling of the great vessels were reviewed. The pulsatile neck masses corresponded to buckling of the innominate and right subclavian arteries in five patients and buckling of the right common carotid arteries in six. Real-time sonography provides a noninvasive and accurate method to diagnose buckling of the great vessels of the neck as the cause of pulsatile neck masses and obviates angiography for diagnosis.