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

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

Surveillance Neck Sonography After Thyroidectomy for Papillary Thyroid Carcinoma: Pitfalls in the Diagnosis of Locally Recurrent and Metastatic Disease

A sonographic examination of the neck performed 6 to 12 months after thyroid surgery in patients with differentiated thyroid cancer is strongly recommended by the American Thyroid Association and considered mandatory by the European Thyroid Association for locoregional surveillance. The aim of this article is to review the normal anatomic changes expected after thyroid surgery and the pathologic mimics of thyroid carcinoma recurrence in post‐thyroidectomy patients as they appear on neck sonography. We hope to offer some pearls to increase diagnostic confidence in this setting.     

Coexistence of Papillary Thyroid Cancer and Hashimoto Thyroiditis in Children

This report documents 3 pediatric papillary thyroid carcinoma cases with associated Hashimoto thyroiditis. In all 3 cases, hypoechoic nodules accompanied by multiple echogenic spots were noted on sonography of the thyroid. Hashimoto thyroiditis was suspected on the basis of positive thyroid autoantibody test results and pathologic examinations of thyroidectomy specimens, which revealed chronic thyroiditis with lymphocytic infiltration as the background of papillary thyroid carcinoma development. The potential for papillary carcinoma development warrants close follow‐up, and meticulous sonographic examinations must be performed in children with Hashimoto thyroiditis.     

Novel operative approach to double primary cancers of the breast and thyroid and its effects on cosmesis and the accuracy of follow‐up examinations

For the treatment of double primary cancer of the breast and thyroid, endoscopic thyroidectomy might be an excellent option in terms of cosmesis; however, it may not offer curability, and it makes the accuracy of follow‐up examinations difficult. The postoperative scars after endoscopic thyroidectomy may modify the estimation of recurrence. To achieve improve cosmesis and the accuracy of follow‐up examination, we developed a novel method for thyroid surgery: hybrid‐type endoscopic thyroidectomy (HET). Here we report two cases of double primary cancer, one synchronous and the other metachronous. HET lobectomy and HET total thyroidectomy were performed in combination with some modifications of breast surgery. In each case, the postoperative course was uneventful, and cosmetic satisfaction was very high. Furthermore, there were no problems during the follow‐up period. Based on our results, HET could become a standardized treatment of double primary cancers.     

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

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

Sonography in the diagnosis of cervical recurrence in patients with differentiated thyroid carcinoma.

OBJECTIVE: To determine the sensitivity of thyroglobulin (Tg), iodine scanning, and sonography in the diagnosis of cervical recurrence of thyroid cancer. METHODS: This prospective study assessed 81 patients with cervical metastases or extrathyroid invasion at first appearance who underwent clinical examination, scanning, measurement of Tg after thyroxine withdrawal, and sonography about 8 months after thyroidectomy followed by radioiodine treatment. Only patients without distant metastases and without anti-Tg antibodies were included. RESULTS: Fifty patients showed persistence of the disease in the cervical region, with only 16% of them having had a suspicion on clinical examination, 33 with Tg levels of 2 ng/mL or greater (66% sensitivity), and 29 with positive scan findings (58% sensitivity). A combination of the 2 methods detected disease in 40 (80%) of 50 patients but failed to show 20% of cases that were identified by sonography and confirmed by fine-needle aspiration. Sonography had sensitivity of 96%. Specificity values for Tg, iodine scanning, and sonography were 80.6%, 90.3%, and 87%, respectively. CONCLUSIONS: Classic follow-up methods may not detect cervical disease in some patients with differentiated thyroid carcinoma, and sonography is necessary even in patients apparently free of the disease.     

Sonographic Features of Placenta Accreta After First‐Trimester Abortion

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

Comparison Between Exclusively Long‐Axis and Multiple‐Axis Sonographic Protocols for Screening of Rotator Cuff Lesions in Symptomatic Shoulders

Objective. The purpose of this study was to determine whether exclusively long‐axis sonography differs from a multiple‐axis scanning protocol as a screening tool for rotator cuff lesions in symptomatic shoulders when compared with magnetic resonance imaging (MRI). Methods. A total of 509 consecutive patients (mean age, 52.8 years) referred for MRI were also routinely evaluated by sonography. We initially performed exclusively long‐axis sonography and graded the rotator cuff as normal or abnormal. Patients subsequently underwent a full sonographic protocol using multiple‐axis views. Magnetic resonance imaging findings were compared with sonographic findings for both techniques. Results. The overall accuracy of sonography was greater than 90%. We found divergent results from different sonographic techniques in 34 patients. Of these, 8 were multiple‐axis false‐negative; 14 were exclusively long‐axis false‐negative; 6 were exclusively long‐axis false‐positive; and 6 were multiple‐axis false‐positive. All cases with divergent false‐negative findings on multiple‐axis sonography showed tendinosis on MRI. Causes for false‐negative findings on exclusively long‐axis sonography included tendinosis and partial‐thickness tears of the supraspinatus. No statistically significant difference was seen between both sonographic techniques compared with MRI in terms of accuracy, sensitivity, specificity, positive predictive value, and negative predictive value (P > .05). Conclusions. Sonography is reliable for detecting rotator cuff abnormalities. Exclusively long‐axis sonography seems appropriate as a screening tool for rotator cuff lesions in symptomatic shoulders.     

Sonographic diagnosis of a large and deep endometrioma of the uterine cervix

We present a rare case of endometriosis of the cervix. Transvaginal sonography showed a 35‐mm cyst in the cervix with diffuse, low‐level internal echoes. Transvaginal sonography‐guided aspiration with a 17‐gauge needle was performed, yielding a very thick chocolate‐colored fluid. Cytological examination of the fluid revealed the presence of endometrial cells. Symptoms resolved after aspiration and no recurrence has developed. © 2010 Wiley Periodicals, Inc. J Clin Ultrasound, 2010     

Sonographic appearance of oxidized cellulose (Surgicel): pitfall in the diagnosis of postoperative abscess.

Oxidized regenerated cellulose (Surgicel) is used for intraoperative hemostasis and frequently is left in the surgical bed. We describe the sonographic appearance of Surgicel, which may mimic an abscess in the postoperative setting. Sonograms from six postoperative patients with retained Surgicel were collected. The use of Surgicel was confirmed by consultation with the operating surgeon. In five patients, correlative CT scans were performed. All cases appeared as echogenic masses with posterior reverberation artifact suggestive of an abscess due to gas forming organisms. In three patients, fluid surrounded the echogenic masses. Correlative CT scans showed that the Surgicel masses contained complex collections of fluid and gas. Five of six patients showed no clinical evidence of an abscess. The presence of echogenic masses with posterior reverberation artifact in postoperative patients should alert the sonologist that Surgicel may have been used, and an appropriate history should be sought.     

Thyroid metastasis from breast cancer presenting with diffuse microcalcifications on sonography: A case report

Microcalcifications are frequently associated with papillary thyroid cancers. Metastatic nodules from extrathyroid malignancies may mimic primary thyroid neoplasm on sonography, but do not present with microcalcifications. We report the case of a 45‐year‐old woman with a history of invasive ductal carcinomas of bilateral breasts, status post surgery and neoadjuvant chemotherapy. Four years after surgery, thyroid sonography revealed diffuse microcalcifications without nodular component. Core needle biopsy confirmed thyroid metastasis from primary breast cancer. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 42 :430–432, 2014     

Straight Vessel Pattern and Rapid Filling Time

Six patients with 7 lesions that were histologically confirmed as primary testicular lymphoma were preoperatively investigated with a standardized sonographic protocol including contrast‐enhanced sonography. Duplex and contrast‐enhanced sonography showed marked hypervascularization in all 7 lesions. On contrast‐enhanced sonography, the filling time of lymphomatous lesions was significantly shorter than the filling time of a size‐matched sample of 10 patients with seminomas (P < .0001). The sonographic hallmarks of testicular lymphoma in our case series were as follows: (1) sharply demarcated homogeneous hypoechoic testicular lesions with marked hypervascularization; (2) a rapid (<7 seconds) filling time of contrast bubbles; and (3) a straight and parallel course of intralesional vessels on contrast‐enhanced sonography.     

Antenatal diagnosis of idiopathic dilatation of pulmonary artery with 3D power doppler imaging

We present a case of antenatal diagnosis of idiopathic dilatation of the pulmonary artery by three‐dimensional power Doppler imaging (HDliveFlow with silhouette mode). Two‐dimensional sonography clearly demonstrated a 10.4‐mm‐diameter fetal pulmonary artery (PA), whereas the aorta (Ao) diameter was 5.04 mm. HDliveFlow clearly demonstrated the spatial relationships and different sizes of PA and Ao. The PA size returned to normal (8.0 mm) on the 11th day after birth (Ao: 9.0 mm). HDliveFlow may be an adjunctive tool to two‐dimensional sonography to diagnose abnormalities of fetal great vessels. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45 :121–123, 2017;     

First Experience Using 4‐Dimensional Hysterosalpingo‐Contrast Sonography With SonoVue for Assessing Fallopian Tube Patency

This study was conducted to describe our first experience using transvaginal 4‐dimensional (4D) hysterosalpingo‐contrast sonography with SonoVue (Bracco International BV, Amsterdam, the Netherlands) for diagnosis of fallopian tube patency. The study was prospective and conducted in a university hospital setting. The sonographic procedures included 2‐dimensional transvaginal sonography for evaluating uterine and ovarian mobility, observing intubation, and determining the initial plane and 4D hysterosalpingo‐contrast sonography for observing periovarian and pelvic diffusion. Ninety‐six outpatients visiting infertility clinics underwent 4D hysterosalpingo‐contrast sonography. All patients finished the examination successfully. A total of 192 fallopian tubes were assessed, of which 95 (49.5%) were classified as type A (the tube was patent, and the contrast agent flowed smoothly through it), 72 (37.5%) as type B (the tube was patent, but the contrast agent did not flow smoothly inside it), and 25 (13.0%) as type C (blocked). Sixteen patients underwent laparoscopy or laparoscopy combined with hysteroscopy; 28 tubes (87.5%) were concordant with laparoscopy. The sensitivity, specificity, positive predictive value, negative predictive value, and Youden index for 4D hysterosalpingo‐contrast sonography versus laparoscopy were 81.8%, 90.5%, 81.8%, 90.5%, and 0.72 respectively. In total, 92.7% of patients did not require a hospital stay after 4D hysterosalpingo‐contrast sonography, and none need resuscitation. The others stayed in the hospital for clinical observation because of a severe vasovagal reaction or severe pain but received only bed rest without any medical treatment. Forty patients (41.7%) felt slight pain; 39 (40.6%) felt moderate pain; and 15 (15.6%) had a vasovagal reaction. No procedure or postprocedure complications occurred in any patient. In conclusion, 4D hysterosalpingo‐contrast sonography with SonoVue is an available screening method for assessment of tubal patency and is tolerable for most patients.     

Comparison of Sonography and Scintigraphy in the Evaluation of Gallbladder Functional Studies With Cholecystokinin

Objective. Both sonography and scintigraphy have been used to evaluate gallbladder function with the use of sincalide (cholecystokinin [CCK]). However, the reported ejection fractions (EFs) for the two modalities are not the same. The techniques measure slightly different parameters. This study directly compared both techniques performed simultaneously on the same participants. Methods. Twenty healthy volunteers were evaluated with sonography and scintigraphy to estimate the gallbladder EF simultaneously. The gallbladder EF was calculated at 5‐minute intervals for 1 hour. Results. The mean EFs ± SD were 66.3% ± 20% and 49% ± 29% for sonography and scintigraphy, respectively. The mean times to the peak EF were 38 ± 12 and 33 ± 9 minutes for sonography and scintigraphy. An average time of 34 minutes was noted after radiopharmaceutical injection before CCK administration for the scintigraphic studies. The earliest time to the peak EF for sonography was 15 minutes, and the latest time to the peak EF was 60 minutes (mode, 40 minutes); for scintigraphy, the earliest and latest times were 15 and 50 minutes (mode, 30 minutes), respectively. One participant could not be evaluated secondary to nonfilling of the gallbladder on scintigraphy. There was wider variability of the gall‐bladder EF with scintigraphy than sonography. Conclusions. Scintigraphy estimated a lower EF than sonography, had wider EF variability than sonography, and required additional time (>30 minutes more) to complete the study. Scintigraphy could not be performed in 5% of the participants because of nonfilling of the gallbladder. The use of sonography to estimate the gallbladder EF is less time‐consuming and less costly. With these techniques, the range of normal gallbladder EFs should be adjusted for the technique used.     

Diagnosis of recurrent lung cancer in the mediastinum using endosonographically guided fine‐needle aspiration biopsy

Endoscopic sonography is a well‐established tool for the diagnosis and staging of gastrointestinal malignancies. It has been found to be of increasing utility in the diagnosis and management of lung cancers. We report a case of recurrent lung cancer presenting 4 years after initial diagnosis and treatment, in which endoscopic sonography was used to guide the fine‐needle aspiration biopsy. © 2009 Wiley Periodicals, Inc. J Clin Ultrasound 2009     

Multiparametric Sonography of Hematologic Malignancies of the Testis: Grayscale,Color Doppler,and Contrast‐Enhanced Ultrasound and Strain Elastographic Appearances With Histologic Correlation

Primary testicular lymphoma is rare and appears with nonspecific findings on grayscale and color Doppler sonography. We present 8 patients further examined with contrast‐enhanced sonography, strain elastography, and histologic analysis after orchiectomy. Seven of 8 patients had a diagnosis of large B‐cell lymphoma, and 1 of 8 had a diagnosis of granulocytic sarcoma, with solitary lesions (2 of 8), multiple lesions (3 of 8), or entire testicular involvement (3 of 8). Lesions appeared hypoechoic (7 of 8) or isoechoic (1 of 8), all with increased vascularity on color Doppler sonography and a nonbranching linear pattern of intratumoral vessels (7 of 8). Contrast‐enhanced ultrasound (CEUS) confirmed this pattern and showed increased enhancement in all lesions. On strain elastography, all lesions were hard, with an elasticity score of greater than 4. Multiparametric sonography of testicular lymphoma identifies increased vascularity on color Doppler and contrast‐enhanced ultrasound and increased lesion stiffness on strain elastography.     

Characteristic Sonographic Findings of Early Restenosis After Carotid Endarterectomy

Objective. Restenosis of the carotid artery after carotid endarterectomy (CEA) is a major complication. The frequency, time of occurrence, and tissue characteristics of carotid restenosis were assessed with sonography. Methods. Two hundred sixteen patients who had CEA for carotid stenosis were studied; follow‐up sonography and magnetic resonance angiography were done 2 weeks, 3 months, and then every year after CEA. On sonography, restenosis was defined as an internal carotid artery (ICA) with a peak systolic velocity of 170 cm/s or greater or a maximum area of stenosis of 90% or greater. Results. During 605 artery‐years of follow‐up, 18 patients (7.5%) were found to have restenosis on sonography: 4 at 3 months, 11 at 1 year, and 3 at 2 years after CEA. At the time that restenosis was detected, in all 18 ICAs the peak systolic velocity exceeded 200 cm/s and had more than doubled since the last measurement (mean ± SD, 103 ± 27 to 321 ±107 cm/s), whereas the area of stenosis exceeded 90% in 6 patients, and magnetic resonance angiography revealed stenosis of 60% or greater in 8 patients. On sonography, all of the restenotic plaques were isoechoic and concentric. The restenosis was asymptomatic in 17 patients. Vascular risk factors or the severity of initial carotid stenosis before CEA were not associated with development of restenosis. Eleven patients had successful endovascular therapy, and the others received medical treatment. Conclusions. A marked increase in the flow velocity through an operated ICA is a good indication of restenosis. The isoechogenicity and concentricity of the restenotic plaques suggest that the restenosis is primarily the result of intimal hyperplasia.     

Follicular Thyroid Carcinoma With an Eggshell Calcification

Objective. The purpose of this series is to report 3 cases of follicular thyroid carcinoma with an eggshell calcification along with their imaging findings. Methods. Imaging findings on gray scale and power Doppler (PD) sonography (n = 3), computed tomography (CT; n = 3), and integrated fluorodeoxyglucose F 18 (¹⁸F‐FDG) whole‐body positron emission tomography (PET)/CT (n = 1) were assessed. Results. Of the 3 cases, two 75‐year‐old women had bone metastasis, and one 54‐year‐old woman had a thyroid incidentaloma on sonography. All 3 cases had a spherical mass with an interrupted eggshell calcification on gray scale sonography and CT; 2 revealed intranodular vascularity on PD sonography, and 1 showed intense hypermetabolism (maximum standardized uptake value, 7.9 g/mL) on integrated ¹⁸F‐FDG whole‐body PET/CT. Conclusions. Follicular carcinoma should be considered in the differential diagnosis of a thyroid nodule with an eggshell calcification.     

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.