Cystic lesions of the breast: sonographic-pathologic correlation

PURPOSE: To understand the pathologic basis for sonographic features of cystic lesions of the breast and determine appropriate assessment and management recommendations for these lesions based on sonographic appearance. MATERIALS AND METHODS: From a database of 2,072 image-guided procedures performed from July 1995 through September 2001, 150 cystic lesions were identified. Diagnosis was established with fine-needle aspiration (n = 55), 14-gauge core-needle biopsy (n = 81), or both (n = 14). Excision was performed for all malignant (n = 18) and atypical (n = 2) lesions and for 11 benign lesions, which recurred or enlarged at follow-up. Imaging follow-up was available for 92 of 119 benign lesions. Targeted sonography was performed with high-frequency (10-MHz center frequency) transducers. Imaging and histopathologic, cytologic, and/or microbiologic findings were reviewed. Lesions were categorized as simple cysts, complicated cysts (imperceptible wall, acoustic enhancement, low-level echoes), clustered microcysts, cystic masses with a thick (perceptible) wall and/or thick (> or =0.5 mm) septations, intracystic or mixed cystic and solid masses (at least 50% cystic), or predominantly solid masses with eccentric cystic foci. RESULTS: Of 150 lesions, 16 were simple cysts aspirated for symptomatic relief. Of 38 lesions characterized as complicated cysts and one cyst with thin septations, none proved malignant, nor did any of 16 lesions characterized as clustered microcysts. Of 23 masses with thick indistinct walls or thick septations, seven proved malignant. Of 18 intracystic or mixed cystic and solid masses, four proved malignant. Of 38 predominantly solid masses with eccentric cystic foci, seven proved malignant. CONCLUSION: Symptomatic complicated cysts generally warrant aspiration. All clustered microcysts were benign, but further study is required. Cystic lesions with thick indistinct walls and/or thick septations (> or =0.5 mm), intracystic masses, and predominantly solid masses with eccentric cystic foci should be examined at biopsy; 18 of 79 of such complex cystic lesions proved malignant in this series.     

18^F-FDG符合线路显像探测不明原因发热病灶的临床价值

目的探讨18^F-脱氧葡萄糖（FDG）双探头符合线路显像探测不明原因发热病灶的临床价值。方法对58例不明原因发热患者（体温超过38．3℃,发热持续时间至少3周）的18^F—FDG符合线路显像资料进行回顾性分析,将18^F—FDG符合线路显像结果与病理检查和随访结果进行比较;用感兴趣区（ROI）技术计算良恶性病变／正常组织放射性（L／B）比值,组间L／B比值比较采用t检验。结果48例（83％）患者有异常的18^F—FDG浓聚,其中20例为恶性病变,23例为感染或其他良性病变,5例未能确诊。58例中,10例（17％）符合线路显像阴性,其中4例为感染性疾病（2例尿路感染,2例淋巴结炎）,3例为结缔组织和胶原病（1例风湿病,1例成人still病,1例系统性红斑狼疮）,3例未能确诊。良恶性病灶的L／B比值分别为1．93±0．39和3．58±1．01,差异有统计学意义（t=6．955,P〈0．001）。结论符合线路显像可为探查不明原因发热患者的病灶提供有价值的临床信息。     

Transrectal sonography of benign and malignant prostatic lesions

Using linear-array transrectal prostate sonography, malignant lesions in 43 patients and benign lesions in 74 patients were evaluated. Prostate sonography was sensitive to textural changes produced by both benign and malignant diseases. However, there was considerable overlap in the sonographic appearances of benign and malignant lesions, and there were no sonographic features that reliably predicted malignancy. Hyperechoic areas were present in 58% of the carcinomas, while 19% were purely hypoechoic. Lesions containing hypoechoic foci that were posterior or posterolateral had a high incidence of cancer. The results confirm the need to biopsy all suspicious palpable lesions of the prostate.     

Differentiation of benign from malignant superficial lymphadenopathy: the role of high-resolution US.

Ultrasonography has proved a valuable tool for the detection of enlarged lymph nodes; however, differentiation between benign and malignant nodal disease remains a problem. High-frequency probes with improved spatial and contrast resolution display superficial nodes to advantage and also show the internal structure of the nodes. Ninety-four superficial nodes in patients with suspected nodal disease were examined by using 7.5-MHz probes to evaluate longitudinal-transverse diameter ratio (L/T), the central hilus, cortical widening, and size. Histologic diagnosis was obtained after sonographic examination in 73 nodes (five reactive nodes, 35 primary nodal malignancies, and 33 nodal metastases). The remaining 21 nodes regressed after either antibiotic or no therapy. Marked differences were observed among the proportions of benign and malignant nodes in terms of L/T, hilus, and cortex; the latter two structures, however, must be interpreted together. Eccentric cortical widening was seen in only malignant nodes. The distribution of nodal size was not significantly (P greater than .1) different for benign and malignant nodes. No differences were observed between primary and secondary nodal malignancies. The sonographic criteria evaluated in this study assist in the differentiation of benign from malignant superficial lymph nodes.     

Sonography in thyroid carcinoma in children.

This paper reviews the clinical, sonographic and pathological findings of 20 children with thyroid carcinoma in an attempt to determine the value and limitations of sonography in thyroid neoplasms in this age group. Although sonography is an excellent technique for the evaluation of thyroid disorders and masses, certain limitations must be kept in mind. Microscopic foci of tumour might be missed and sonography cannot predictably differentiate benign from malignant disease. Previous radiation exposure should increase the level of suspicion for malignancy.     

Simple pancreatic cysts: CT and endosonographic appearances

OBJECTIVE. This report describes the CT and endoscopic sonographic appearance of simple pancreatic cysts in three adults. CONCLUSION. Simple pancreatic cysts are typically an incidental finding in adults who have no history of pancreatic disease. The imaging characteristics of simple pancreatic cysts on CT and endosonography are similar to those of benign cysts.     

乳腺肿块的热断层成像分析

目的:探讨乳腺肿块在热断层成像系统(TTM)中热源的特点。方法:将乳腺肿块106例病人进行TTM检查,与病理结果对照,从乳腺异常热源的形态、结构、深度及热辐射值来分析良、恶性病变在TTM上的表现。结果:病理结果恶性病变49例,良性病变57例,TTM在乳腺良、恶性肿瘤诊断与病理诊断的符合率为89.5%和91.9%,良、恶性肿瘤热辐射值分别为1.822和2.599(P<0.001),深度在良、恶性肿瘤中也有明显差异。结论:恶性病变的形态多不规则,结构密实,热辐射值较高,良性病变则相反;TTM在乳腺良、恶性肿瘤的鉴别诊断中有重要的价值。     

Detection of clinically unexpected malignant and premalignant tumors with whole-body FDG PET: histopathologic comparison

PURPOSE: To determine the clinical importance and malignant potential of unexpected abnormal foci of hypermetabolism at fluorodeoxyglucose (FDG) positron emission tomography (PET) performed for evaluation of malignancy. MATERIALS AND METHODS: A total of 1,750 FDG PET scans were obtained to evaluate a variety of known or suspected malignancies. Each scan was evaluated for abnormal unexpected hypermetabolism based on unusual location (ie, foci that did not conform to the usual distribution of metastases given the primary tumor for which the PET scan was requested) and discrete focal nature of an abnormality. Unexpected findings were followed by pathologic confirmation and were considered clinically important if the final pathologic diagnosis was cancerous, precancerous, or noncancerous but had the potential for local destruction or systemic physiologic effects. RESULTS: On the basis of the normal spread pattern of the primary lesion, 58 abnormal unexpected foci of hypermetabolism were identified in 53 patients. Forty-five of these abnormalities were followed up with computed tomography (CT), magnetic resonance imaging, and/or mammography, and 42 had subsequent tissue confirmation at endoscopic, CT-guided, or surgical biopsy. Of 42 histopathologically confirmed abnormalities, 30 (71%) were either malignant or premalignant tumors that differed from the cancer for which the patient was originally scanned. Nine other suspicious abnormal foci proved benign and three represented false-positive findings, with no abnormal findings at endoscopy. Three of nine nonmalignant lesions were considered clinically important because of the potential for local destruction and/or systemic effects. CONCLUSION: The identification of unexpected foci of hypermetabolism at whole-body FDG PET may signal the presence of tumors that are unrelated to the neoplasm for which the patient was scanned. Findings of this study emphasize the need for follow-up of these abnormalities because the majority represent either malignant or premalignant neoplasms, which were not clinically apparent.     

Sonographic criteria for differentiation of benign and malignant solid breast lesions: size is of value

PURPOSE: The purpose of this study was to evaluate whether lesion size may influence the value of sonographic findings in the differential diagnosis between benign or malignant breast lesions. MATERIALS AND METHODS: Sonographic features of 256 histologically confirmed (148 benign, 108 malignant) breast lesions were retrospectively and independently reviewed by three radiologists unaware of mammographic findings and pathology results. Each lesion was assessed for several sonographic features and assigned a level of suspicion. Logistic modelling defined the predictive value of each sonographic feature per se and in relation to lesion size. The k statistic (k) evaluated interobserver agreement in lesion classification. The accuracy of breast sonography in characterising solid lesions was also evaluated. RESULTS: Analysis of the sonographic features predictive of malignant disease, taken as a whole, showed that only irregular margins and marked hypoechogenicity maintain their predictive value independent of lesion size. When lesion size is considered, the other features remain significant only for lesions larger than 7 mm. Interobserver agreement for sonographic suspicion, when calculated not taking into account lesion size, was good or excellent whereas it was reduced for lesions smaller than 7 mm. Accuracy of breast sonography improved when evaluating lesions larger than 7 mm. CONCLUSIONS: Lesion size influences the value of sonographic findings in distinguishing benign from malignant lesions. The usually adopted criteria in sonography have a significantly lower accuracy in characterisation of small lesions.     

Role of ultrasound in the assessment of benignity and malignancy of parotid masses

OBJECTIVES: This study aimed to investigate the value of ultrasound in the identification of benign and malignant parotid masses. Methods: Data of 189 patients with parotid gland masses undergoing ultrasound-guided fine-needle aspiration (FNA), core biopsy or surgery were reviewed retrospectively and the presumed sonographic diagnoses were compared with the histopathology. The sensitivity, specificity and accuracy of sonographic diagnoses were assessed and the sonographic characteristics of those lesions, including shape, margin, echogenicity, echotexture and vascularization, were studied. Results: Of the 189 patients, the final pathological diagnosis included 18 malignant tumours and 171 benign masses; the presumed sonographic diagnoses showed 165 cases as benign and probably benign masses (11 cases were confirmed malignant, 154 cases benign) and 24 cases were diagnosed as probably malignant and malignant masses (7 cases were confirmed malignant, 17 cases benign). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of ultrasound for the diagnosis of parotid gland masses were 38.9%, 90.1%, 29.2%, 93.3% and 85.2%, respectively, and accuracy for malignant masses was 20%. The sonographic characteristics of parotid masses between benign and malignant lesions had no significant differences. The parotid gland masses in this study included pleomorphic adenoma, Warthin's tumour, retention cyst, haemangiomas, chronic granuloma, lymphoma, fibrolipoma, abscess, basal cell adenoma, oncocytoma, lymphatic tuberculosis, myoepithelioma, neurilemmoma, mucoepidermoid carcinoma, adenoid cystic carcinoma, alveolar soft part sarcoma and retinal blastoma (metastasis). CONCLUSIONS: It is challenging to use sonography for differentiating between benign and malignant parotid gland masses. To make a definite diagnosis, ultrasound-guided FNA or core biopsy is advocated.     

SPECT／CT显像在股骨头颈或转子区病变鉴别诊断中的应用

目的探讨SPECT／CT融合显像在单个股骨头颈部或转子区病变诊断中的应用价值。方法在2007年1月至2008年6月进行^99Tc^m-亚甲基二膦酸盐（MDP）全身骨显像的患者中,94例股骨头颈或转子区异常放射性分布不能明确诊断,遂行SPECT／CT显像,并通过随访得到患者的病理诊断或综合影像诊断。对病变的SPECT图像、CT图像及SPECT／CT融合图像的诊断符合率进行对比,并分析转移性肿瘤及良性病变的影像特征。采用SPSS13．0软件行McNemar检验。结果排除失访及最后未明确诊断者,最终入选患者78例。根据随访结果,确定良性病灶59例,转移性肿瘤19例。SPECT、CT及融合图像对78例病灶的诊断符合率分别为59．0％（46／78）,87．2％（68／78）,96．2％（75／78）,SPECT、CT图像分别与融合图像比较,差异均有统计学意义（χ^2=16．48和48．18,P均〈0．05）。结论在对肿瘤患者进行骨显像中发现的股骨头颈或转子区病变以良性病变居多,SPECT／CT融合显像可提高其诊断准确性。     

Scrotal sonography in infants and children

In this review we will attempt to summarize the use of scrotal sonography in infants and children. The material is gathered from the literature and from our own experience of 197 sonograms performed on 175 pediatric patients. Included will be information on testicular development and descent, normal sonographic anatomy, classification of scrotal disease, and the final diagnoses of the sonograms. Scrotal sonography has proven useful in evaluating undescended testes in the inguinal canal and just inside the inguinal ring. It is of limited value when the testes are in the abdomen. Sonography can often distinguish the various causes of nonpainful scrotal masses such as tumors, hydrocele, and meconium peritonitis. Sonography is highly accurate in distinguishing normal from abnormal scrotal contents and in separating testicular from extratesticular masses. However, sonography does have limitations in distinguishing benign from malignant neoplasms or from some inflammatory lesions.

Sonography can be successfully used in the differential diagnosis of the painful scrotum especially with color flow Doppler. Inflammatory diseases that often involve the epididymis can be distinguished from torsion. Torsion of the appendages has been diagnosed.

In cases of scrotal trauma, management decisions are often based on the sonographic findings. Conditions that require surgical management such as testicular rupture or large testicular hematomas can be recognized. Information is included on a variety of miscellaneous conditions such as hydrocele, varicocele, and ambiguous genitalia in which sonography has proven valuable.     

The distinction between benign and malignant liver tumors on sonography: value of a hypoechoic halo.

OBJECTIVE. The purpose of this study was to determine the diagnostic value of the sonographic halo sign (defined as any hypoechoic rim in the periphery of a lesion) in distinguishing between benign and malignant isoechoic and hyperechoic liver lesions on sonography. MATERIALS AND METHODS. Sonograms of the liver in 50 patients with proved benign liver tumors and in 50 patients with proved malignant liver tumors (seven primary liver neoplasms, 43 metastases) selected during a 13-month period were retrospectively analyzed by four radiologists who had no knowledge of the patients' clinical findings or the final diagnoses. Only a single sonogram was studied in each case. The presence or absence of a hypoechoic halo on the sonogram was the only criterion for distinguishing malignant from benign hepatic lesions. RESULTS. For 95 of 100 hepatic lesions, the four radiologists were almost (three vs one) or completely (four vs zero) in agreement about the presence or absence of a hypoechoic halo. In the five cases where there were conflicting decisions (two vs two), a final decision (four vs zero) was achieved by reviewing the entire series of sonographic images. A halo could be detected in 44 malignant tumors (88%) and in only seven benign tumors (14%) (sensitivity, 88%; specificity, 86%; positive and negative predictive values, 86% and 88%, respectively). The sonographic halo sign was particularly helpful in distinguishing hemangiomas (n = 29) from metastases (n = 43) (positive and negative predictive values, 95% and 87%, respectively). CONCLUSION. The results of this study suggest that the halo sign on sonograms is useful to distinguish benign from malignant isoechoic or hyperechoic tumors.     

Echogenic material in the fetal gallbladder: sonographic and clinical observations.

Obstetric sonograms of 26 fetuses with echogenic material in the gallbladder were reviewed to describe the sonographic findings and clinical significance. Gestational age at the time of diagnosis ranged from 28 to 42 weeks (mean, 36.2 weeks). The echogenic foci were associated with distal shadowing in eight fetuses (30%), comet-tail artifact in nine (35%), and no distal artifact in nine (35%). No hemolytic anemias, other predisposing risk factors, or clinical sequelae associated with biliary tract disease were identified in any of the infants. Postnatal sonographic or pathologic follow-up studies were available in 17 cases. In nine of these 17 infants, the echogenic foci had resolved. In three, the foci have persisted, but none of the children have become symptomatic; the longest period of follow-up with stones still present is 4 1/2 years. Whether all echogenic foci in the fetal gallbladder represent true gallstones remains unknown. Echogenic foci may be seen in the fetal gallbladder during the third trimester. No predisposing fetal risk factors or clinical sequelae were evident in our series. Many echogenic foci, but not all, will resolve.     

Foci of eosinophil-related necrosis in the liver: imaging findings and correlation with eosinophilia

OBJECTIVE: The purpose of our study was to describe CT and sonographic findings of foci of eosinophil-related hepatic necrosis and to correlate those findings with eosinophil counts in the peripheral blood. MATERIALS AND METHODS: We retrospectively reviewed 17 helical CT and 16 sonographic examinations (including follow-up examinations) in 10 patients with pathologically proven foci of eosinophil-related necrosis. Underlying causes were anisakiasis (n = 2), malignant neoplasms (n = 3), hypereosinophilic syndrome (n = 3), and idiopathic (n = 2). CT and sonographic images were reviewed by consensus by three radiologists, with an emphasis on the morphology and distribution of foci. Imaging findings were correlated with eosinophil counts in the peripheral blood. RESULTS: All foci of eosinophil-related necrosis were observed as focal hypoattenuating lesions on all phases of helical CT and as focal hypoechoic lesions on sonography. Foci varied in size and were round or oval. The number of these foci seemed to be in proportion to the percentage of eosinophils in the peripheral blood. Most foci showed interval regression on follow-up CT or sonography as peripheral blood eosinophil counts decreased. CONCLUSION: Foci of eosinophil-related necrosis cause focal hepatic lesions of varying size, shape, and number on helical CT and sonography. The number and extent of these foci were closely correlated to eosinophil counts in the peripheral blood.     

肺孤立性结节的CT探讨(附38例分析)

目的:观察肺内孤立性结节灶(≤3cm)形态特点,主要分析CT扫描(包括薄扫、HRCT)对良恶性病变定性诊断的作用。材料和方法:选择肺内孤立结节38例,采用常规平扫,增强及薄层、HRCT技术,对其病灶内部、边缘、周围改变特征进行分析。结果:恶性结节28例,良性结节10例。由手术病理证实,CT诊断正确率71％。仅见于恶性结节的征象有空泡征、空气支气管征,深分叶征,脐凹征,周围支气管变形,周围局限性肺气肿等。其余一些征象既见于恶性结节灶,也见于良性结节灶,就其在两类结节灶中的出现率而言,短毛刺、棘状突起,血管集束征,胸膜凹陷征多见于恶性结节,出现率53％～71％。而浅分叶征,长毛刺征、轨道征,卫星灶多见于良性病变,出现率30～50％,结论:对SPN进行CT薄扫、HRCT技术对提高病变特征显示率有意义,能做出大部分良恶性病变的定性诊断。对于缺乏特异性病变者应根据多个良性或恶性征象进行判断,结合临床,综合考虑。     

Importance of evaluating all vascular phases on contrast-enhanced sonography in the differentiation of benign from malignant focal liver lesions

OBJECTIVE: Our objective was to evaluate the accuracy of a blood-pool sonographic contrast agent in the late phase compared with the three vascular phases for differentiation between benign and malignant focal liver lesions. SUBJECTS AND METHODS: In 152 patients (105 with chronic liver disease), 152 solid focal liver lesions characterized either by fine-needle biopsy or by dynamic CT or MRI were studied. The final diagnoses were metastasis for 24, hepatocellular carcinoma for 75, focal nodular hyperplasia for 13, regenerating or dysplastic nodule for 14, hemangioma for 22, cholangiocarcinoma for two, and another focal liver lesion for two. Real-time sonography was performed after a bolus injection of 2.4 mL of SonoVue, using a low mechanical index (< 0.2). All lesions were evaluated in the arterial, portal, and late phases; classified as benign or malignant; and correlated with final diagnoses. RESULTS: For discrimination between malignant and benign focal liver lesions, evaluation of all vascular phases improved the sensitivity from 78.4% to 98% and the accuracy from 80.9% to 92.7%, compared with evaluation of the late phase alone. The increase in accuracy was higher in patients with chronic liver disease (16.3%) than in those without (2.1%). CONCLUSION: Evaluation of SonoVue enhancement in all three vascular phases is superior to evaluation of SonoVue enhancement in the late phase alone, especially in patients with chronic liver disease.     

The role of magnetic resonance imaging and ultrasound in patients with adnexal masses

AIMS: To evaluate the accuracy of ultrasonography (US) and magnetic resonance imaging (MRI) in characterizing adnexal masses, and to determine which patients may benefit from MRI. METHODS: We prospectively studied 72 women (mean age 53 years, range 19 to 86 years) with clinically suspected adnexal masses. A single experienced sonographer performed transabdominal and transvaginal greyscale spectral and colour Doppler examinations. MRI was carried out on a 1.5T system using T1, T2 and fat-suppressed T1-weighted sequences before and after intravenous injection of gadolinium. The adnexal masses were categorized as benign or malignant without knowledge of clinical details, according to the imaging features which were compared with the surgical and pathological findings. RESULTS: For characterizing lesions as malignant, the sensitivity, specificity and accuracy of MRI were 96.6%, 83.7% and 88.9%, respectively, and of US were 100%, 39.5% and 63.9%, respectively. MRI was more specific (p<0.05) than US. Both MRI and US correctly diagnosed 17 (24%) cases with benign and 28 (39%) cases with malignant masses. MRI correctly diagnosed 19 (26%) cases with benign lesion(s), which on US were thought to be malignant. The age, menopausal status and CA-125 levels in these women made benign disease likely, but US features were suggestive of malignancy (large masses and solid-cystic lesions with nodules). CONCLUSION: MRI is more specific and accurate than US and Doppler assessment for characterizing adnexal masses. Women who clinically have a relatively low risk of malignancy but who have complex sonographic features may benefit from MRI.     

Sonography of diffuse benign liver disease: accuracy of pattern recognition and grading

Sonograms of 110 patients were compared to recently performed liver biopsies for evaluation of the accuracy of sonography in predicting the type (pattern) of pathology and its grade of severity (mild, moderate, or severe) in a wide variety of diffuse liver processes. There are two distinct, abnormal sonographic patterns: the fatty-fibrotic pattern seen primarily with cirrhosis, chronic hepatitis, and/or fatty infiltration, and the centrilobular pattern seen primarily with acute hepatitis. Sonography was 88% accurate in assigning the correct pattern to the corresponding pathology (sensitivity 89%, specificity 86%, p less than 0.001). The degree of accuracy was dependent on the grade of pathologic severity, with mild disease offering the greatest difficulty; moderate and severe diseases were accurately detected and placed in the correct pattern in all cases. Sonographic grading of the severity of disease was far less precise (63% overall). This study showed that sonography can distinguish between two abnormal sonographic patterns of diffuse benign liver disease as well as between normal and abnormal patterns.