Ultrasonography of cystic thyroid nodules: sonographic-pathologic correlation

Retrospectively the ultrasonographic findings of 153 surgically resected cystic thyroid nodules were reviewed. The pathologic findings in this series revealed that 86% were degenerating benign adenomas or adenomatous goiters, and 14% were malignant tumors. The sonographic appearance of these lesions was classified into 7 groups as follows: type I: entirely cystic (less than 1cm), type II: cystic(more than 1cm) [II(a)], and with small polyp or dome-like elevation on the cyst wall [II(b)], type III: larger cyst with projection (more than 1cm) into the lumen, type IV: cyst with a peripherally localized solid component, type V: irregularly mixed cystic and solid components, type VI: a solid mass with multiple crescentic cysts [VI(a)], or round cysts [VI(b)], type VII: a solid mass with only one or two cysts. Pathologic correlation revealed that malignancy in this series ranged from 80% in type III and V to only 4% in type II, where most of the lesions in this group were composed of granulation tissue in degenerating adenomatous polyps and cyst walls. Lesions in type IV showed malignancy rate of 40%. Type III showed characteristic sonographic findings seen in cystic papillary carcinomas (CPCs), with multiple punctate echogenic foci in large pedunculated projections. The typical psammomatous calcifications specific in this group were confirmed in 6 of the 8 type III CPCs. The multiple crescentic cysts in type VI(a) lesions were characteristic sonographic signs seen in adenomatous goiters, representing the pathologic finding of cysts forming around each of multiple adenomatous nodules in this group. Type VII represented non specific appearing lesions, included adenomas, adenomatous goiters, CPCs and follicular carcinomas.(ABSTRACT TRUNCATED AT 250 WORDS)     

Extended analysis of AL-amyloid protein from abdominal wall subcutaneous fat biopsy: kappa IV immunoglobulin light chain

OBJECTIVE: HIV-associated nephropathy is an important cause of morbidity that is characterized clinically by uremia and proteinuria and histologically by focal segmental glomerulosclerosis. In the largest series yet analyzed to our knowledge, we describe new sonographic findings and record the prevalence of other findings. We review the sonographic findings in a large group of HIV-infected patients. MATERIALS AND METHODS: Seventy-six consecutive HIV-infected patients underwent renal sonography. Abnormalities seen on sonography were recorded. RESULTS: Of 152 kidneys imaged, sonography showed that 30 kidneys (20%) were enlarged. Abnormal echogenicity was present in 136 kidneys (89%). Eighty-one kidneys (53%) were globular; 58 (38%) had decreased corticomedullary definition; 74 (49%) had decreased renal sinus fat; and 66 (43%) had heterogeneous parenchyma, some with echogenic striations. CONCLUSION: Our data reveal several sonographic abnormalities that have not previously been described: decreased corticomedullary definition, decreased renal sinus fat, parenchymal heterogeneity, and globular renal configuration. These new findings were found mainly in patients with advanced HIV infection.     

Guidelines to determine the route of oophorectomy with hysterectomy

OBJECTIVES: Our purpose was to determine whether there is adequate visibility and access for transvaginal oophorectomy in most patients and the success rate of the transvaginal approach. The final goal was to establish objective guidelines for choosing the route of oophorectomy with hysterectomy. STUDY DESIGN: Patients underwent laparoscopy-assisted vaginal hysterectomy (n = 91) or vaginal hysterectomy (n = 875). Ovarian removal, either unilateral (n = 97) or bilateral (n = 187), was carried out for clinical or prophylactic reasons. The accessibility of the ovaries for transvaginal removal was assessed by stretching the infundibulopelvic ligament and grading the position of the ovaries from 0 (no descent) to III (descent past the hymenal ring with traction). RESULTS: In 158 patients transvaginal bilateral oophorectomy was performed without laparoscopic assistance. In another 29 patients bilateral transvaginal oophorectomy was performed with laparoscopy-assisted vaginal hysterectomy, and prophylactic bilateral oophorectomy by the transvaginal route was successful in all but 1 of 143 patients with ovaries of grade I or higher. In 20 patients laparoscopic lysis of adhesions was necessary to permit transvaginal oophorectomy. Ninety-seven patients underwent transvaginal unilateral oophorectomy, 74 with conventional vaginal hysterectomy and 23 with laparoscopy-assisted vaginal hysterectomy. Among the patients not having oophorectomy, all ovaries had sufficient mobility to have been removed transvaginally. CONCLUSION: Good surgical practice dictates that visibility and accessibility be the primary criteria for selecting the route of oophorectomy with hysterectomy. In most patients the ovaries are visible and accessible to transvaginal removal.     

JSJ-1, an anti-spermidine monoclonal antibody with potential clinical applications

Thirtysix patients with persistent gestational trophoblastic disease were analysed in The Clinic of Cancer of Female Reproductive System. Using transvaginal USG, the volume of pathological foci within myometrium, diametre of theca lutein ovarian cysts and uterus length before, during and after the treatment were registred. In order to check the effectiveness of USG examination in the monitoring of GTD treatment particular USG factors were compared with hCG level. On 28 patients (77.7%) in USG examination pathological changes in uterus and ovaries were seen. The relation between hCG level and tumor volume, uterus length and theca lutein ovarian cysts was stated. That proves the usefulness of transvaginal USG examination in the monitoring of treatment of patients with persistent gestational trophoblastic disease.     

Sonographic diagnosis of peritoneal inclusion cysts

Peritoneal inclusion cysts have not received the attention they merit in the imaging literature. We present a series of peritoneal inclusion cysts and describe their sonographic features. Our findings lead us to encourage more conservative therapies. All seven patients in our series had pelvic pain and had undergone surgery previously. An ovary surrounded by septations and fluid was the most common finding by transvaginal sonography. Doppler examination showed low resistive flow in the septations. Conservative therapy was used in five cases with excellent results. We found that a confident diagnosis of peritoneal inclusion cysts is possible with ultrasonography. This diagnosis should encourage the use of more conservative therapy.     

Hyperreactio luteinalis in pregnancy

We report on the extremely rare case of ovarian overstimulation in a single pregnancy without prior hormonal stimulation therapy. During the 26th week of gestation ultrasound examination showed a 103 x 57 x 78 mm polycystic tumour with echogenic structures inside the cysts, located behind the uterus. Further management consisted of laparotomy with partial resection of a cystic part of the left ovary. Frozen section examination confirmed the diagnosis of hyperreactio luteinalis and excluded malignancy. To avoid torsion of the ovaries, cysts from both sides were aspirated. On day 8 and 18 after surgery, sonography revealed no pathological finding. In the 40th week of gestation, a healthy baby was delivered. The possibility of a hyperreactio luteinalis has to be kept in mind, when cystic solid tumours of the ovaries are diagnosed during pregnancy. A conservative management is appropriate, because a normal spontaneous remission occurs after delivery.     

Endobronchial sonography: feasibility and preliminary results

Endobronchial sonography, a new ultrasound technique, has been evaluated for the assessment of normal lungs and bronchial carcinomas. The procedure was performed with ultrasound catheters, which were introduced into central and peripheral bronchi through the operating channel of fibreoptic bronchoscopes. The bronchial wall is highly echogenic and laminated. The lung parenchyma appears echo rich and patchy. Pulmonary arteries can be identified by the pulsatile changes and floating echoes within the echo free lumen. Echo poor bronchial carcinomas were detected in 69 out of 74 patients with endoscopically visible tumours and in 19 out of 26 patients with peripheral carcinomas. The correct implantation of metallic stents was facilitated by endobronchial sonography in nine patients. The sonographic examination carried no particular risk and caused little discomfort.     

Septate uterus: detection and prediction of obstetrical complications by different forms of ultrasonography

The aims of the study were to compare the accuracy of transvaginal ultrasonography, transvaginal color Doppler sonography, hysterosonography, and three-dimensional ultrasonography in detection of septate uterus and to evaluate the occurrence of obstetrical complications in relation to septal dimension and vascularity. Each patient underwent transvaginal ultrasonography and color Doppler examination, whereas hysterosonography and three-dimensional ultrasonography were carried out in 76 and 86 patients, respectively. The sensitivity of different sonographic imaging modalities ranges between 95.21% and 99.29%. Color and pulsed Doppler sonographic studies of the septal area revealed vascularity in 71.22%. Patients with vascularized septa had a higher prevalence of obstetrical complications than those with avascularized septa (P < 0.05). Three-dimensional ultrasonography and hysterosonography are highly accurate diagnostic tools for detection of uterine septa. We found no correlation between septal dimension and rate of obstetrical complications, although pregnancy loss was most likely to occur in patients with vascularized septa.     

A monitoring, feedback, and triggering system for reproducible breath-hold MR imaging

OBJECTIVE: To evaluate the diagnostic accuracy and clinical usefulness of high-resolution transvaginal duplex Doppler ultrasound in postpartum and post-abortion patients with excessive hemorrhage who are suspected of having residual trophoblast. METHODS: Forty-eight women with excessive hemorrhage referred for possible residual trophoblastic tissue were evaluated by transvaginal duplex Doppler ultrasonography. Based on two-dimensional imaging, the patients were divided prospectively into groups: women who had an empty uterus with a normal uterine cavity, those with a pure endometrial fluid collection and no echogenic foci, those who had a mixed endometrial fluid collection with foci of echogenicity, and those with intracavitary heterogeneous material with mixed echo patterns of fluid and solid components. In each group, Doppler studies were performed and the resistance index (RI) was calculated. The two-dimensional patterns and Doppler results were correlated with clinical and pathologic follow-up. RESULTS: Twenty-eight subjects had a normal uterine cavity and seven had a pure endometrial fluid collection; all were treated conservatively and none showed later clinical evidence of residual trophoblastic tissue. In 13 women, residual trophoblast was strongly suggested from the images of two-dimensional ultrasonography: Five showed an endometrial fluid collection with some echogenic foci, and eight exhibited intracavitary mixed echogenic material. All underwent curettage, and residual trophoblastic tissue was found in ten of the 13. The mean (+/- standard deviation) RI to flow in the myometrial arteries was 0.54 +/- 0.15 in women without residual trophoblast and 0.35 +/- 0.1 in those with residual trophoblastic tissue (P < .01). CONCLUSION: Our experience suggests that transvaginal duplex Doppler ultrasonography is an effective noninvasive method for evaluating patients with excessive postpartum and post-abortion hemorrhage who are suspected of having residual trophoblastic tissue. Its use enhances the positive preoperative diagnosis of residual trophoblastic tissue and may reduce unnecessary curettage procedures.     

Sonographic features of mammary oil cysts

Mammographic lesions that are pathognomonic for oil cysts require no further evaluation. Oil cysts, however, may first be discovered by ultrasonography. Between 1988 and 1995, we performed sonography of 26 oil cysts in 15 patients. Sonography was used to evaluate a palpable finding when an oil cyst was not initially perceived on the mammogram (47%) or as an initial evaluation of a palpable lump (33%); in addition, oil cysts were identified incidentally in 20% of cases. Retrospective review showed that the sonographic appearance of oil cysts is highly variable; only 8% mimic simple apocrine cysts. Twelve percent mimic an intracystic mass. Most have smooth walls (88%), are hypoechoic (65%), and have neither enhancement or shadowing (50%). The sonographic appearance of oil cysts can be suggestive of a pathologic lesion such as an intracystic carcinoma. Unnecessary biopsy can be avoided using directed mammography.     

Hemangioma of the left ventricular cavity: presumptive diagnosis by magnetic resonance imaging

Eleven patients with sickle hemoglobinopathies undergoing sonographic examinations for reasons unrelated to renal parenchymal disease were incidentally noted to have increased echogenicity in the central portion of the renal parenchyma. This appearance was observed to be a continuum, with some cases showing focally hyperechoic medullary pyramids at one extreme and other cases showing a diffusely echogenic central parenchymal region relative to a thin band of hypoechoic cortical or peripheral parenchyma at the other extreme. The finding of hyperechoic medullae of the kidneys has been reported in patients having conditions associated with hyperuricemia, medullary nephrocalcinosis, or hypokalemia. This sign has not been commonly reported as a finding in patients with sickle syndrome. The thin hypoechoic rim of cortical parenchyma relative to a more echogenic central parenchyma has not been commented on previously.     

Sonographic features of ovarian remnants

Ovarian remnants occur after a portion of ovarian tissue is left behind unintentionally after oophorectomy. The ovarian remnant may be functional and cystic, producing pelvic pain and, in some patients, extrinsic compression of the distal ureter. Ovarian remnants frequently are associated with adhesions from previous pelvic surgery for endometriosis or pelvic inflammatory disease. Ovarian remnants also may be included within pelvic peritoneal inclusion cysts. In this retrospective study, the sonographic features of ovarian remnants in 10 patients with surgical proof or clinical follow-up data are described. Most ovarian remnants were simple cysts (seven of 10), three had multiple septations, and six had a rim of presumably ovarian tissue with arterial and venous flow. Three patients with ovarian remnant masses that were aspirated had symptomatic relief without recurrence. In one patient, guided aspiration was unsuccessful, probably owing to the presence of organized hemorrhage within the mass. Extrinsic compression of the distal ureter was observed in one patient, who was treated with gonadotropin releasing hormone agonist (Lupron). The sonographic findings of a completely cystic or multiseptated pelvic mass with a rim of vascularized solid tissue in a postoophorectomy patient, although such cases are rare, suggest the diagnosis of an ovarian remnant. If the diagnosis can be established with a high degree of certainty, sonographically guided aspiration may be attempted in an effort to provide symptomatic relief. Otherwise, sonography is useful in serial assessment of these masses in patients receiving medical treatment.     

Effects of oxygen and carbon dioxide on mean cell volume

PURPOSE: Renal sonography is an accepted primary imaging modality for evaluating the pediatric urinary tract. We report a new sonographic finding associated with vesicoureteral reflux (VUR). METHODS: Ten patients underwent sonographic evaluation of the kidneys and were noted to have intermittent renal collecting system dilatation that expanded and contracted during real-time scanning. These patients were further evaluated with voiding cystourethrography. RESULTS: All 10 patients were proven to have VUR on the side of the sonographic abnormality. Four patients had bilateral VUR for a total of 14 refluxing renal units. Of these 14 renal units, 1 was sonographically normal. Five of the 14 renal units had grade V VUR that required surgical reimplantation of the ureter. CONCLUSIONS: This new finding of intermittent renal collecting system dilatation may become an important predictor of VUR. The finding warrants further evaluation even when detected in patients not suspected of having VUR who are undergoing renal sonography for other reasons.     

"Tower vertebra": a new observation in sickle cell disease

PURPOSE: We studied the frequency of testicular microlithiasis (TM) in a select group of otherwise healthy infertile men with abnormal semen. METHODS: We reviewed scrotal sonography records of 180 consecutive patients with abnormal semen who were referred for evaluation of male infertility. The pampiniform plexus was evaluated for possible varicocele, and the testes were examined for the presence or absence of intratesticular calcifications and/or masses. Five patients with more than 5 echogenic foci per transducer field in either testis were identified. The medical records and sonograms of this subgroup of patients were analyzed. RESULTS: Of the 180 patients, 5 (2.8%) had TM. Three patients with TM had concomitant small varicoceles; 2 others had a history of testicular maldescent. Two patients eventually became fertile. CONCLUSIONS: Our results indicate a higher than expected frequency of TM in otherwise healthy infertile men. We speculate that the magnitude of hypospermatogenesis in patients with TM is variable and may relate to both the degree of testicular dysgenesis and the presence or absence of concomitant scrotal pathology (eg, scrotal varicocele and cryptorchidism).     

Laparoscopy for ovarian pathology in infancy and childhood

INTRODUCTION: Nonparasitic splenic cysts are a rare finding: they can be distinguished into true cysts (epidermoid or epithelial) cysts or false (pseudocysts), depending on the presence/absence of an inner epithelial lining. They are usually found during the second and third decade of life, although they can also appear during childhood. They grow bigger in children, becoming clinically apparent due to the symptoms of compression of adjacent structures. The diagnosis is radiological, made with ultrasonography (US) and computed tomography (CT). We report the US and CT patterns of splenic cysts to differentiate true from false cysts. MATERIAL AND METHODS: Our series consists of 5 patients, aged 5-17 years, all examined with US and CT; one of them was also submitted to plain abdominal radiography. Conventional CT was used in 2 cases and helical CT in the extant 3. RESULTS: All examinations yielded useful clinical informations. The only radiograph showed the rightward displacement of the gastric gas bubble US always identified the cyst and its pertinence to splenic parenchyma, although failing to assess the liquid/solid nature of a highly echogenic cyst in one case. CT confirmed the cystic nature of all masses and showed the lack of contrast enhancement of cyst walls and the presence of septa or parietal calcifications. DISCUSSION: Radiological examinations, particularly US and CT, can diagnose splenic cysts unquestionably, correctly defining the relationships with adjacent organs. CT is more sensitive than US in detecting septa or calcifications, which are definitely useful findings to distinguish true from false cysts, since internal septa are more frequent in true cysts while parietal calcifications are typical of pseudocysts. The final diagnosis, however, is made at histology.     

Sonographic appearance of ovaries and gonadotropin secretions as prognostic tools of spontaneous puberty in girls with Turner's syndrome

We evaluated the possibility of anticipating spontaneous puberty in peripubertal Turner girls, in order to plan substitutive estrogen treatment. In the 24 patients studied, spontaneous puberty was seen in 4/11 girls with 45 XO karyotype, 5/5 with mosaicisms, 1 out of 2 with structural aberrations of the X chromosome and 0 out of 6 with Xq isochromosomes. When considering sonographic findings, the 6 girls with normal ovaries and 4/9 of those with intermediate ovarian appearance showed spontaneous puberty; the remaining 5 with intermediate ovaries and 9 with streak gonads did not undergo spontaneous puberty. Gonadotropin secretion was normal in girls with normal ovaries, moderately elevated in patients with intermediate ovarian appearance, and very high in those with streak gonads. The prognostic value of sonography and gonadotropins is particularly important in girls with intermediate ovaries. Therefore these evaluations should be performed at peripubertal age in patients with Turner's syndrome to elucidate the degree of ovarian insufficiency.     

Hepatic hydatid cysts: sonographic follow-up after percutaneous sonographically guided aspiration

PURPOSE: We studied the sonographic appearances of hepatic hydatid cysts and used sonography to follow up these cysts after sonographically guided aspiration using the PAIR technique. METHODS: Included in this study were 362 patients with 558 hepatic hydatid cysts. Initial sonographic examination revealed 510 noncomposite cysts and 48 composite cysts (18 rosette and 30 honeycomb pattern). Noncomposite hydatid cysts (510 cysts) were aspirated and treated with scolicidal agents using the PAIR technique. Sonographic follow-up was done for up to 5 years after aspiration. RESULTS: There was immediate detachment of the germinal layer in all cysts during aspiration. There were no serious complications. Sonographic follow-up after 1 month and 1 year revealed complete cyst collapse in 326 cysts (64%) and 449 cysts (88%), respectively. Repeat ultrasound scanning showed a continued decrease in the sizes of all remaining cysts. Organized lesions (pseudosolid pattern) were detected in only 26 cases after up to 5 years of follow-up. CONCLUSIONS: The most common sonographic appearance of hepatic hydatid cysts among Egyptians is noncomposite, anechoic cysts. The PAIR technique is a safe, effective, and inexpensive therapeutic modality.     

Sonographic detection of pneumoperitoneum: an experimental and clinical study

The sonographic appearance of intraperitoneal air collection has been studied in 46 patients. In 30 patients (group I), a pneumoperitoneum had been iatrogenically induced either during aspiration of ascitic fluid or during laparoscopy. Three normal volunteers (group II) had been subjected to graded intraperitoneal air injection to quantify the smallest amount of air detectable by ultrasound (US). In eight patients (group III) the sonographic demonstration of free intraperitoneal air led to a diagnosis of hollow visceral perforation; whereas in another five patients (group IV) the sonographic findings reinforced the clinical suspicion of a 'sealed off' perforation in the presence of negative roentgenograms. In all patients intraperitoneal air was seen as an echogenic line with a posterior reverberation or ring down artefact. In patients with free air, this was best seen in the perihepatic spaces with the patient in the supine, left lateral decubitus or prone position. As little as 5 mL of air could be consistently detected in all three volunteers (group II). Artefacts leading to a pseudopneumoperitoneum on US included; (i) the artefacts distal to an overlying rib; (ii) ring-down artefact from air in the adjacent lungs; and (iii) hepatodiaphragmatic interposition of colon. With proper sonographic technique and principles of interpretation these can be distinguished from true intraperitoneal air. Although sonography may be more informative than conventional radiology in patients with hollow visceral perforation, we did not find it more sensitive than conventional roentgenograms in detecting free intraperitoneal air. Sonography, however, is distinctly superior in patients with a sealed off perforation in whom conventional roentgenograms are frequently negative.     

Nonparasitic splenic cysts. Ultrasonographic features and follow-up

Sixty-three patients with splenic cysts, multiple in 7 cases, were reviewed. Only 3 patients had a history of previous abdominal trauma. The cysts ranged in size from less than 1 cm to 15 cm. They were anechoic in 40 patients, hypoechoic in 16, isoechoic in 4, mixed in one, and in 2 cases the echogenicity could not be assessed due to thick marginal calcifications. The echogenic cysts were larger than the anechoic ones and frequently calcified, and the findings at surgery, fine-needle aspiration biopsy and follow-up suggested the echogenicity to be related to a fresh or previous episode of intracystic hemorrhage. Initially, surgical treatment was undertaken on 10 patients, electively in 9 cases and due to cyst rupture in one. At follow-up (n = 37), the size of the cyst had increased markedly over several years in only 2 patients, necessitating delayed surgery in one. Routine follow-up of asymptomatic splenic cysts was of no clinical value.     

Splenorenal shunt blood flow by transit-time ultrasound as an index of collateral circulation in portal hypertensive rats

OBJECTIVE: The purpose of this study was to explore the role of sonography for women with urethral symptoms and a suspected urethral diverticulum. SUBJECTS AND METHODS: Nineteen women with urethral symptoms underwent voiding cystourethrography (VCUG) and transvaginal, transperineal, and urethral sonography (using a catheter-based transducer). VCUGs and sonograms were evaluated for diverticula, defined on sonography by direct visualization of the neck connecting the periurethral sac with the urethral lumen. The diverticular neck, size, location, and shape were noted. Lesions revealed by sonography as not connected to the urethra were also noted. RESULTS: Of 19 women, 14 had urethral diverticula and one had two diverticula, for a total of 15 diverticula. On sonography the diverticula ranged in diameter from 2 mm to 5 cm. Both sonography and VCUG showed 13 of the 15 diverticula. In addition, sonography revealed two infected periurethral cysts, a periurethral leiomyoma, a diffuse urethritis, and scarring or deformity of one patient's urethra from a prior diverticulectomy. On sonography, eight of the 13 diverticula wrapped around more than 50% of the urethral circumference. The neck was precisely seen (by definition) in 13 of 15 diverticula on sonography and in two of 13 diverticula on VCUG. CONCLUSION: Sonography is useful in this group of women with urethral symptoms and suspected urethral diverticula. It provides information on the extent and location of the diverticular neck, both of which are important in surgical excision. Also, sonography provides information on lesions not connected to the urethra. Sonography may prove useful in a broader group of women with urethral symptomatology.