Breast ultrasound: An opportunity to detect unsuspected pleural and pulmonary abnormalities.

PURPOSE: While scanning women for breast US, is possible to observe changes in the appearance of the pleural line or in the most superficial portion of the lung. The objective of this single-center, prospective study was to determine the prevalence of a variety of pleural and pulmonary US findings during routine breast US. METHODS: In this study, there were 200 women undergoing standard breast US examination. The presence of pleural and pulmonary abnormalities in these cases was recorded. Two off-site reviewers confirmed the presence of pleura and lung changes. RESULTS: There was no abnormal finding in 168 out of 200 cases (84%) while there were one or more abnormal findings in 32 cases (16%). Pleural effusion was observed in 0.5% of cases, thickening of the pleural line 5% of cases, irregularity of the pleural line in 6% of cases, increased number of vertical artifacts in 9% of cases, subpleural nodulations in 2% of cases, and lung consolidation in 0.5%. CONCLUSION: Pleural and lung changes are not uncommon during breast US. Operators performing breast US examinations should be aware of the possibility to identify unsuspected pleuro-pulmonary abnormalities.

Ultrasound Assessment of Skin Tumors Local Recurrence.

Skin cancer may recur at or around the surgical site despite wide excisions. Prompt clinical and sonographic detection of local recurrence is important since subjects with relapsing melanomas or nonmelanoma malignancies can be managed efficaciously, with a relevant impact on morbidity and survival. Ultrasound is being employed with increasing frequency in the assessment of skin tumors, but most of the published articles relate to initial pretherapeutic diagnosis and staging. This review aims to offer an illustrated guide to the sonographic evaluation of locally recurring skin cancer. We introduce the topic, then we provide some sonographic tips for patient follow-up, then we describe the ultrasound findings in case of local recurrence, illustrating the main mimickers, and finally, we mention the role of ultrasound in guiding diagnostic and therapeutic percutaneous procedures.

Recent Advances in Ultrasound Breast Imaging: From Industry to Clinical Practice.

Breast ultrasound (US) has undergone dramatic technological improvement through recent decades, moving from a low spatial resolution, grayscale-limited technique to a highly performing, multiparametric modality. In this review, we first focus on the spectrum of technical tools that have become commercially available, including new microvasculature imaging modalities, high-frequency transducers, extended field-of-view scanning, elastography, contrast-enhanced US, MicroPure, 3D US, automated US, S-Detect, nomograms, images fusion, and virtual navigation. In the subsequent section, we discuss the broadened current application of US in breast clinical scenarios, distinguishing among primary US, complementary US, and second-look US. Finally, we mention the still ongoing limitations and the challenging aspects of breast US.

Non-glandular findings on breast ultrasound. Part II: a pictorial review of chest wall lesions.

The breast ultrasound (US) field-of-view (FOV) includes glandular parenchyma as well as tissues located anterior to and posterior to it, up to pleural line. For that, it is possible to incidentally identify lesions unrelated to breast parenchyma during screening or diagnostic US; sometimes a palpable lump may be the reason of the imaging exam. Furthermore, abnormality related to chest wall are easier and more accurate detected after mastectomy. Hence, radiologists should know the US appearance of lesions which may develop from all tissues present in this region and displayed in the US FOV, without focusing only on glandular abnormalities while performing the exam. This is the second of a two-part series on non-glandular breast lesions; in detail, part two provide an overview of US appearance, differential diagnosis, and pitfalls of chest wall lesions. They may have an infectious, traumatic, inflammatory etiology or be benign or malignant neoplasms. The US role in the assessment of chest wall abnormalities is limited, usually computed tomography and/or magnetic resonance are requested as second-level imaging exams to characterize and to assess better their relationship with surrounding structures because of larger and panoramic view. Finally, US could be useful to guide biopsy.

Use of new microcirculation software allows the demonstration of dermis vascularization.

AIMS: Current ultrasound (US) Doppler techniques cannot demonstrate the vascularization of the dermis. The purpose of this study was to investigate whether the new Superb Vascular Imaging (SMI) and Microvascular Flow (MV-Flow) techniques improve the detection of normal dermis vessels. SMI and MV-Flow were compared side-by-side to conventional power-Doppler (PD) imaging. METHODS: By using US, 50 healthy volunteers were evaluated at level of five body areas: forehead, forearm, palm, buttock, and thigh. Two off-site operators evaluated the images to assess the difference between SMI and PD imaging and between MV-Flow and PD imaging in terms of dermis flow amount. A 0-3 scoring system was adopted. RESULTS: SMI scored grade 0 in 0% of body areas, grade 1 in 58%, grade 2 in 33%, and grade 3 in 9%. In comparison with SMI, PD scored grade 0 in 38% of body areas, grade 1 in 56%, grade 2 in 6%, and grade 3 in 0%. MV-Flow scored grade 0 in 0% of body areas, grade 1 in 52%, grade 2 in 43%, and grade 3 in 6%. Comparted to MV-Flow, PD scored grade 0 in 53% of body areas, grade 1 in 34%, grade 2 in 13%, and grade 3 in 0%. The difference in terms of sensitivity was statistically significant for all the body areas investigated. CONCLUSIONS: We found both SMI and MV-Flow to be superior to PD imaging and capable to demonstrate normal vascularization of the dermis.

Use of High-Frequency Transducers in Breast Sonography.

Sonography companies have recently developed high-frequency transducers (20-30 MHz) to image the skin and small joints. In this pictorial review, we present a number of settings where these probes can be usefully employed to scan the breast. These include skin abnormalities of the breast and axilla; nipple-areolar complex abnormalities; superficial breast parenchyma abnormalities; breast parenchyma abnormalities in subjects with implants; very small female breasts; peripheral areas in breasts of any size; pre-puberal breasts; male breasts; post-mastectomy chest wall; and intraoperative breast sonography. Comparatively, side-by-side images obtained with conventional breast frequencies and high frequencies are shown.

Interventional Ultrasound in Dermatology: A Pictorial Overview Focusing on Cutaneous Melanoma Patients.

Cutaneous melanoma incidence is increasing worldwide, representing an aggressive tumor when evolving to the metastatic phase. High-resolution ultrasound (US) is playing a growing role in the assessment of newly diagnosed melanoma cases, in the locoregional staging prior to the sentinel lymph-node biopsy procedure, and in the melanoma patient follow-up. Additionally, US may guide a number of percutaneous procedures in the melanoma patients, encompassing diagnostic and therapeutic modalities. These include fine needle cytology, core biopsy, placement of presurgical guidewires, aspiration of lymphoceles and seromas, and electrochemotherapy.

Non-glandular findings on breast ultrasound. Part I: a pictorial review of superficial lesions.

Ultrasound (US) represents the first-level imaging technique in the assessment of breast in young patients, whereas it is complementary to mammography in adult ones. It is not uncommon to encounter non-glandular mass during either screening or diagnostic breast US; sometimes the evaluation of palpable lump may be the reason of clinician's US request. The breast US field-of-view includes not only the glandular parenchyma, but also the tissues located anterior and posterior to it, from the skin to the ribs. In this setting, the radiologist must be familiar with the non-glandular breast diseases, which can occur in the superficial layers as well as in the chest wall. The differential diagnosis varies according to anatomic layer, so the anatomic origin is the first feature to assess and the correct localization is needed to avoid misdiagnosis and to choose, when requested, the second diagnostic step, imaging or histologic analysis. This paper is the first of two focused on non-glandular breast lesions; characterization, differential diagnosis, and pitfalls of superficial lesions are reviewed. They may be located in the dermis or hypodermis: the former are usually benign skin lesions, whereas the latter, although usually benign, may arise also from the anterior terminal lobular units, hence the papilloma, fibroadenomas, and breast cancers should be included in the differential diagnosis. US is more sensitive than CT and MRI in the assessment of superficial lesions due to higher spatial resolution.

Seeing the unseen with superb microvascular imaging: Ultrasound depiction of normal dermis vessels.

PURPOSE: Current color- and power-Doppler techniques cannot demonstrate vascularization of the dermis. Aim of this prospective study was to investigate whether the new superb vascular imaging (SMI) technique improves the ultrasound (US) depiction of dermis vessels in healthy volunteers. SMI was compared side-by-side to conventional power-Doppler (PD) imaging. METHODS: Thirty adult subjects (18 men and 12 women, mean age 45 years old) were evaluated with US at level of five body areas: forehead, forearm, palm, buttock, and thigh. The vascular index (VI) was employed to objectively quantify the difference between SMI and PD imaging in terms of dermis flow amount. RESULTS: Forehead VI was higher for SMI than for PD in 93% of cases, forearm VI was higher for SMI than for PD in 97% of cases, palm VI was higher for SMI than for PD in 87% of cases, buttock VI was higher for SMI than for PD in 100% of cases, thigh VI was higher for SMI than for PD in 100% of cases. SMI-detected vascular signals in 100% of the body areas. PD failed to show any flow signals from the forehead in 23% of cases, forearm in 37% of cases, palm in 33% of cases, buttock in 47% of cases, and thigh in 50% of cases. CONCLUSION: SMI can demonstrate normal dermis vascularization whereas conventional PD cannot. SMI is a sensitive and promising technique in the study of dermis abnormalities, particularly when quantifying the disease activity is important.

MRI Radiomics in Prostate Cancer: A Reliability Study.

BACKGROUND: Radiomics can provide quantitative features from medical imaging that can be correlated to clinical endpoints. The challenges relevant to robustness of radiomics features have been analyzed by many researchers, as it seems to be influenced by acquisition and reconstruction protocols, as well as by the segmentation of the region of interest (ROI). Prostate cancer (PCa) represents a difficult playground for this technique, due to discrepancies in the identification of the cancer lesion and the heterogeneity of the acquisition protocols. The aim of this study was to investigate the reliability of radiomics in PCa magnetic resonance imaging (MRI). METHODS: A homogeneous cohort of patients with a PSA rise that underwent multiparametric MRI imaging of the prostate before biopsy was tested in this study. All the patients were acquired with the same MRI scanner, with a standardized protocol. The identification and the contouring of the region of interest (ROI) of an MRI suspicious cancer lesion were done by two radiologists with great experience in prostate cancer (>10 years). After the segmentation, the texture features were extracted with LIFEx. Texture features were then tested with intraclass coefficient correlation (ICC) analysis to analyze the reliability of the segmentation. RESULTS: Forty-four consecutive patients were included in the present analysis. In 26 patients (59.1%), the prostate biopsy confirmed the presence of prostate cancer, which was scored as Gleason 6 in 6 patients (13.6%), Gleason 3 + 4 in 8 patients (18.2%), and Gleason 4 + 3 in 12 patients (27.3%). The reliability analysis conversely showed poor reliability in the majority of the MRI acquisition (61% in T2, 89% in DWI50, 44% in DWI400, and 83% in DWI1,500), with ADC acquisition only showing better reliability (poor reliability in only 33% of the texture features). CONCLUSIONS: The low ratio of reliability in a monoinstitutional homogeneous cohort represents a significant alarm bell for the application of MRI radiomics in the field of prostate cancer. More work is needed in a clinical setting to further study the potential of MRI radiomics in prostate cancer.

Diagnostic imaging of parotid gland oncocytoma: a pictorial review with emphasis on ultrasound assessment.

Parotid gland oncocytoma (PGO) is a rare benign epithelial tumor that usually occurs in the elderly population. The most common clinical presentation is a painless, slow-growing, non-tender, lobulated, and mobile mass. Histologically, it is composed of monotonous sheets of epithelial cells (oncocytes) with a central scar. The cross-sectional appearance is not specific, and it overlaps with other parotid lesions. On ultrasound (US), oncocytoma appears as an ovoid, well-defined, homogeneous, and hypoechoic lesion. Cystic and hemorrhagic areas as well as intralesional fat may be observed. Doppler analysis shows intratumoral vessels, sometimes with a spoke-wheel pattern. The peak systolic flow is high (up to 100 cm/sec). Furthermore, oncocytoma is avid of FDG on a PET scan, as well as a malignant tumor. Thus, a combined clinical, imaging, and pathologic assessment is essential to establish the most accurate diagnosis and plan the best treatment. US, combined with Doppler techniques, can play an important role in suggesting the diagnosis and confirming it through percutaneous sampling. The purpose of this review is to show the imaging findings in PGO, with special emphasis on the US appearance.

A bump: what to do next? Ultrasound imaging of superficial soft-tissue palpable lesions.

Soft-tissue palpable lesions are common in clinical practice, and ultrasound (US) represents the first imaging option in the evaluation of a patient with a soft-tissue swelling. A full and systematic US assessment is necessary, however. This includes grayscale, color- and power-Doppler, spectral-Doppler, and possibly elastography facilities, as well as a trained operator. Several lesions showing characteristic US features can be diagnosed confidently, without any further work-up, and the high spatial resolution of ultrasound in the superficial layers can be a powerful tool to discriminate their etiologies. Second-level options, to be reserved for indeterminate cases or those suspected malignant at initial ultrasound, include magnetic resonance imaging, percutaneous fine-needle aspiration or biopsy, and surgical-excision biopsy. In this article, we discuss the proper US approach for addressing superficial soft-tissue lesions.

Skin cancer: findings and role of high-resolution ultrasound.

Currently available high-resolution transducers allow a detailed ultrasound (US) assessment of skin tumors. US complements clinical examination, dermoscopy, and biopsy in the initial differential diagnosis, surgical planning, locoregional staging, and follow-up of patients with skin malignancies. It is important for dermatologists, skin surgeons, and US operators to be aware of the US imaging findings and to recognize the clinical scenarios where imaging is indicated in the management of skin cancer. The purpose of this review article is to address the most common indications for US in skin oncology and to provide a comprehensive guide to the gray-scale and color-Doppler findings in cutaneous malignant tumors.

Diastasis of rectus abdominis muscles: patterns of anatomical variation as demonstrated by ultrasound.

PURPOSE: The aim of our study was to categorise the anatomical variations of rectus abdominis muscle diastasis (diastasis recti) by using ultrasound (US). MATERIAL AND METHODS: In a one-year period 92 women were evaluated with US because of suspected diastasis of rectus muscles. Patients were examined in a supine position, with head extended, upper limbs aligned to the trunk, and knees flexed. US was performed with high-frequency, broad-band transducers. Trapezoid field-of-view and extended field-of-view were employed to measure diastasis exceeding 5 cm. Diastasis was defined as a margin-to-margin distance > 20 mm at rest and classified according to the following anatomical patterns: open only above the navel, open only below the navel, open at the navel level, open completely but wider above the navel, and open completely but wider below the navel. RESULTS: Diastasis was found in 82 patients (30-61 years old, mean age 35 years). The width was 21-97 mm, mean 39 mm. The prevalence and severity of the anatomical patterns was as follows: open only above the navel in 48 patients (21-88 mm, mean 40 mm), open only below the navel in one patient (33 mm), open at the navel level in seven patients (23-39 mm, mean 34 mm), open completely but wider above the navel in 24 patients (21-97 mm, mean 41 mm), open completely but wider below the navel in two patients (21-29 mm, mean 25 mm). CONCLUSIONS: The above-navel patterns of recti muscle diastasis are the most common. Even when open completely, diastasis is usually wider above the navel. Knowledge of the anatomical type of rectus muscle diastasis could be of value to the patient (exercises to do and to avoid) and to the surgeon (abdominoplasty planning).

The role of MRI in predicting Ki-67 in breast cancer: preliminary results from a prospective study.

PURPOSE: In the last decade contrast-enhanced magnetic resonance imaging (MRI) has gained a growing role as a complementary tool for breast cancer diagnosis. Currently the relationship between the kinetic features of a breast lesion and pathologic prognostic factors has become a popular field of research. Our aim is to verify whether breast MRI could be considered a useful tool to predict Ki-67 score, thus resulting as a breast cancer prognosis indicator. METHODS: From June to December 2014, we enrolled patients with breast cancer who underwent preoperative dynamic contrast-enhanced MRI at the local health agency. We analyzed the time-signal intensity curves calculating the mean values of the following parameters: the basal enhancement (Ebase), the enhancement ratio (ENHratio), the maximum enhancement (Emax), and the steepest slope of the contrast enhancement curve (Smax). Scatterplots and Pearson correlation test were used to investigate the eventual associations among these parameters. RESULTS: A total of 27 patients underwent breast MRI during the study period. The mean ± SD Ki-67 percentage was 27.03 ± 16.8; the mean Emax, Smax, Ebase, and ENHratio were 433.9 ± 120.2, 267.3 ± 96.8, 165.5 ± 77.1, and 187.1 ± 94.8, respectively. Scatterplots suggest a positive correlation between Ki-67 and both Emax and Smax. The correlation tests between Ki-67 and Emax, Ki-67 and Smax showed statistical significance. CONCLUSIONS: Our preliminary data suggest that enhancement pattern is closely linked to breast cancer proliferation, thus proving the relationship between more proliferating tumors and more rapidly enhanced lesions. This is hypothesis-generating for further studies aimed at promoting breast MRI in the early estimation of cancer prognosis and tumor in vivo response to chemotherapy.

An Exceptional Case of Complete Septate Uterus With Unilateral Cervical Aplasia (Class U2bC3V0/ESHRE/ESGE Classification) and Isolated Mullerian Remnants: Combined Hysteroscopic and Laparoscopic Treatment.

STUDY OBJECTIVE: To report the combined hysteroscopic and laparoscopic treatment of a complete septate uterus with unilateral cervical aplasia (class U2bC3V0/ESHRE/ESGE classification) and isolated mullerian remnants. DESIGN: Step-by-step presentation of the surgical treatment (Canadian Task Force classification 4). SETTING: Complete septate uterus with unilateral cervical aplasia (formally Robert's uterus) is characterized by the presence of a uterine septum completely dividing the endometrial cavity into an obstructed hemicavity and a contralateral nonobstructing hemicavity connected normally to the existing cervix. It has always been described as isolated without any associated anomaly. PATIENT: A 30-year-old woman was referred to our department for dysmenorrhea and primary infertility. Hysterosalpingography showed the presence of a right (RT) hemiuterus with a patent fallopian tube; further evaluation with 2- and 3-dimensional ultrasound and magnetic resonance imaging showed an externally normal-appearing uterus, a right normal hemicavity connected normally with the existed cervix and, a left hemicavity fully divided from the right one by a complete septum and not connected with the cervix. Interestingly, a peculiar complex mass with cystic areas, attached posterolaterally from the left side to the uterine wall at the level of the isthmus and the upper cervix, was also diagnosed. INTERVENTIONS: The study protocol was approved by our local institutional review board. During outpatient hysteroscopy, a right uterine hemicavity with a single ostium was identified without any communication with the left hemicavity. The patient was then scheduled for combined laparoscopic and hysteroscopic treatment. During laparoscopy, a normal uterine body with multiple myomas and a pseudocystic lesion attached posteriorly and left laterally to the uterus at the level of the isthmus and the upper cervix were shown; no communication between the cystic part of that lesion and the isthmus or the cervicovaginal canal was observed. During hysteroscopy, a longitudinal incision of the septum with a 5F bipolar electrode was performed; the left hemicavity was opened, and the corresponding tubal ostium was identified. The pseudocystic lesion was then excised after opening and sent for pathological analysis; the defect was closed with interrupted intracorporeal knots. MEASUREMENTS AND MAIN RESULTS: A single normal endometrial cavity with both tubal ostia was obtained, thus restoring obstruction by unification of the uterine cavity. A histologic report of the removed pseudocystic lesion was compatible with the diagnosis of mullerian remnants. A follow-up hysteroscopy 3 months after showed a normal uterine cavity without postsurgical adhesions. CONCLUSION: The use of 3-dimensional ultrasound and magnetic resonance imaging in combination with the new ESHRE/ESGE classification system gives the opportunity to obtain a precise representation of the female genital anatomy even in the presence of complex anomalies. Although a septate uterus with unilateral cervical aplasia has been already described, the presence of mullerian remnants is a rare entity associated with cyclic pelvic pain, thus needing adequate recognition and treatment. The combined hysteroscopic and laparoscopic approach offers a unique opportunity for the treatment of complex anomalies.