Folic acid improves arterial endothelial function in adults with hyperhomocystinemia.

OBJECTIVES: To evaluate whether oral folic acid supplementation might improve endothelial function in the arteries of asymptomatic adults with hyperhomocystinemia. BACKGROUND: Hyperhomocystinemia is an independent risk factor for endothelial dysfunction and occlusive vascular disease. Folic acid supplementation can lower homocystine levels in subjects with hyperhomocystinemia; however, the effect of this on arterial physiology is not known. METHODS: Adults subjects were recruited from a community-based atherosclerosis study on healthy volunteers aged 40 to 70 years who had no history of hypertension, diabetes mellitus, hyperlipidemia, ischemic heart disease or family history of premature atherosclerosis (n = 89). Seventeen subjects (aged 54 +/- 10 years, 15 male) with fasting total homocystine levels above 75th percentile (mean, 9.8 +/- 2.8 micromol/liter) consented to participate in a double-blind, randomized, placebo-controlled and crossover trial; each subject received oral folic acid (10 mg/day) and placebo for 8 weeks, each separated by a washout period of four weeks. Flow-mediated endothelium-dependent dilation (percent increase in diameter) of the brachial artery was assessed by high resolution ultrasound, before and after folic acid or placebo supplementation. RESULTS: Compared with placebo, folic acid supplementation resulted in higher serum folate levels (66.2 +/- 7.0 vs. 29.7 +/- 14.8 nmol/liter; p < 0.001), lower total plasma homocystine levels (8.1 +/- 3.1 vs. 9.5 +/- 2.5 micromol/liter, p = 0.03) and significant improvement in endothelium-dependent dilation (8.2 +/- 1.6% vs. 6 +/- 1.3%, p < 0.001). Endothelium-independent responses to nitroglycerin were unchanged. No adverse events were observed. CONCLUSION: Folic acid supplementation improves arterial endothelial function in adults with relative hyperhomocystinemia, with potentially beneficial effects on the atherosclerotic process.

Magnetic resonance coronary angiography with 3D TrueFISP: breath-hold versus respiratory gated imaging.

To compare the diagnostic accuracy of coronary magnetic resonance angiography with three-dimensional (3D) trueFISP breath-hold and respiratory gated techniques for the detection of significant coronary artery stenosis. 15 patients who recently underwent elective coronary angiogram were studied and a total of 60 arteries and 48 arteries were assessed by breath-hold and respiratory gated 3D trueFISP techniques, respectively. The image quality, length of artery visualized and the presence or absence of significant coronary artery stenosis were recorded. 83.3% and 81.7% of the arteries obtained with the respiratory gated and the breath-hold techniques, respectively, had an image quality suitable for further analysis. There was no significant difference in the length of artery visualized. Sensitivity and specificity of 80%, 100% and 75% and 100%, respectively, were obtained with the breath-hold and respiratory gated techniques in detecting significant stenosis in the coronary arteries. Both techniques have moderate sensitivity and high specificity in detection of significant stenosis in the visualized segments of the major coronary arteries. However, they cannot replace conventional coronary angiogram for diagnosing coronary artery disease at present. Further studies are required to evaluate whether breath-hold approach is more efficient, therefore should be performed first and respiratory gated approach reserved for those who cannot breath-hold.

Visceral fat and cardiovascular risk factors in Chinese NIDDM patients.

OBJECTIVE: The interrelations between obesity, glucose intolerance, hypertension, dyslipidemia, and insulin resistance are well recognized. These relationships are of particular interest in Hong Kong's Chinese population, in whom increasing affluence has coincided with a marked increase in the prevalence of NIDDM. We designed a pilot study to examine the relationships between visceral fat and cardiovascular risk factors in Chinese NIDDM patients. RESEARCH DESIGN AND METHODS: We studied 21 Chinese NIDDM patients whose visceral fat was quantified by magnetic resonance imaging. Cardiovascular risk factors including plasma lipids and 24-h ambulatory blood pressure (BP) were measured. In addition, insulin resistance was determined by a short insulin tolerance test (SITT). RESULTS: Increased visceral adiposity was significantly correlated with plasma triglycerides (r = 0.63, P = 0.004), the total cholesterol/HDL cholesterol ratio (r = 0.61, P = 0.008), the urinary albumin/creatinine ratio (r = 0.49, P = 0.04), and decreased insulin sensitivity as measured by the SITT (r = 0.47, P = 0.03). When the data were analyzed by tertiles, increasing visceral fat area was associated with higher plasma triglycerides, lower HDL cholesterol, and a smaller plasma glucose decrement during the SITT. In addition, the diurnal rhythm in BP and heart rate tended to be best preserved in those with the least visceral obesity. CONCLUSIONS: This pilot study demonstrates that visceral fat accumulation is associated with dyslipidemia, hypertension, insulin resistance, and albuminuria in Chinese patients with NIDDM.

Color velocity imaging quantification in the detection of intracranial collateral flow.

BACKGROUND AND PURPOSE: The development of intracranial collateral circulation is associated with a lower risk of stroke. A noninvasive technique that can reliably detect the presence of intracranial collaterals would be a valuable factor in the assessment of risk in patients with occlusive cerebrovascular disease. METHODS: Color velocity imaging quantification was used to measure the blood flow volume of the common carotid and vertebral arteries in 40 patients with carotid occlusive disease. The blood flow volumes in these arteries were correlated with angiographic evidence of collaterals to establish the best cutoffs for detecting intracranial collateral circulation. RESULTS: A blood flow volume of either > or =370 mL/min in the common carotid artery or > or =120 mL/min in the vertebral artery was indicative of the presence of intracranial collaterals. The sensitivity and specificity for the common carotid artery were 92.3% [95% confidence interval (CI), 62.1 to 99.6] and 92.1% (95% CI, 77.5 to 97.9), respectively. The sensitivity and specificity for the vertebral artery were 75.0% (95% CI, 35.6 to 95.5) and 87.5% (95% CI, 66.5 to 96.7), respectively. CONCLUSIONS: Color velocity imaging quantification offers a noninvasive, accurate method for detecting the presence of intracranial collateral circulation and quantifying its magnitude. This technique would be a useful adjunct in screening or continuous monitoring of patients with severe carotid occlusive disease.

Radiation pneumonitis after selective internal radiation treatment with intraarterial 90yttrium-microspheres for inoperable hepatic tumors.

PURPOSE: To investigate the clinical, histopathological, and radiological features of radiation pneumonitis arising as a complication of selective internal radiation treatment for liver tumors. To correlate the development of radiation pneumonitis with the degree of lung shunting as assessed by 99mTechnetium-labeled macroaggregated albumin (Tc-MAA) scan. METHODS AND MATERIALS: Five out of 80 patients who had inoperable hepatic tumors and underwent treatment with intraarterial 90Yttrium- (90Y)-microspheres, developed progressive restrictive ventilatory dysfunction without an infective or cardiovascular cause. Histopathological evidence of a pneumonitis and the presence of microspheres in the lung tissue suggested a diagnosis of radiation pneumonitis. The clinical course, radiological and histopathological findings, percentage tumor shunting to the lungs (lung shunting, as predicted by gamma camera scanning after intraarterial Tc-MAA), and the estimated radiation dose to the lungs were analyzed. In an attempt to reduce pulmonary shunting of the microspheres, three patients received partial hepatic embolization with inert particles before selective internal radiation therapy. RESULTS: In the five patients who developed radiation pneumonitis, lung shunting percentages (as predicted by Tc-MAA scan) ranged from 13.1 to 45.6% (median 23.7%). The estimated whole lung radiation dose ranged from 10.43 Gy to 36.44 Gy (median 25.04 Gy). Among 75 patients who did not develop radiation pneumonitis, the percentage lung shunting ranged from less than 1% to 15% (median 6%). Nine patients had lung shunting greater than 13% and five of them developed radiation pneumonitis, whereas this developed in none of those in whom shunting was below 13%. The onset of radiation pneumonitis ranged from 1 to 6 months after internal radiation treatment. All five patients exhibited characteristic plain radiographic and computerized tomographic changes comprising extensive consolidation with well-defined lateral margins. Clinical improvement after corticosteroid treatment was seen in two patients. Three patients died from respiratory failure and two from other causes. Partial hepatic arterial embolization reduced the degree of lung shunting to less than 13%, but did not prevent the development of radiation pneumonitis. CONCLUSION: Radiation pneumonitis may become a complication after intraarterial 90Y-microspheres treatment when lung shunting, as assessed by Tc-MAA scan, is high (above 13%). Prescribed activity of 90Y and lung shunting of Tc-MAA should be considered together before giving selective internal radiation (SIR) therapy for hepatic tumors, and preferably avoided if the lung shunting is above 13%.

Measuring lung shunting in hepatocellular carcinoma with intrahepatic-arterial technetium-99m macroaggregated albumin.

UNLABELLED: With increased use of intraarterial administration of chemotherapeutic and radioactive particulate agents, it is necessary to assess agent delivery in the lung. METHODS: Technetium-99m-labeled macroaggregated albumin (99mTc-MAA) delivered through the hepatic artery was used to determine the degree of lung shunting in 125 patients with hepatocellular carcinoma (HCC). RESULTS: The percentage of lung shunting varied among patients and it ranged from less than 1% to 67.2%, with a median of 8.1%. The degree of shunting depended on the vascularity of the tumors but not on the tumor size. The effect of angiotensin II on lung shunting was tested on six patients and there was no significant difference found between those patients who were pre-treated with angiotensin II and those who were not. One patient who underwent a liver resection, had a significant decrease in lung shunting from 28.5% to less than 1% after surgery. CONCLUSION: The lack of effect of angiotensin II together with the almost complete ablation of lung shunting by tumor resection suggested neoplastic blood vessels were responsible for the shunting.

Selective internal radiation therapy with intra-arterial iodine-131-Lipiodol in inoperable hepatocellular carcinoma.

UNLABELLED: From August 1990 to June 1993, 26 patients with inoperable hepatocellular carcinoma were treated with intra-arterial iodine-131-Lipiodol (131I-L). METHODS: Iodine-131-Lipiodol was given through either an implantable arterial port (9 patients) or during hepatic angiography (17 patients). All 26 patients had multiple lesions, 3 had involved resection margin after surgical resection and 1 had diffuse infiltrative lesions. The median size of the largest tumor among 22 patients with a measurable lesion was 4.5 cm (2-9.5 cm). The end points are tumor response in terms of tumor size, change in serum alpha-fetoprotein level, toxicity of treatment and overall survival. RESULTS: Twenty-three patients received a single treatment of 1.11-2.22 GBq (30-60 mCi)131I-L. Three patients received 2.22-4.44 GBq (60-120 mCi)131I-L in three fractions. Considering both radiological regression and reduction in serum alpha-fetoprotein level as objective response criteria, the overall response rate was 52% (13 out of 25 patients with evaluable disease). Ten out of 15 patients who had raised alpha-fetoprotein levels had more than 50% reduction and 8 patients had more than 90% reduction in alpha-fetoprotein level. Since analysis, 19 patients have died and 7 remain alive, giving a minimum median survival of 6 mo (range 1.2-16.6 mo), with 4 surviving more than 1 yr calculated from the day of treatment. There was only one patient who had late deterioration of liver function compatible with radiation hepatitis. There was no bone marrow toxicity documented in any patients. CONCLUSION: Treatment with intra-arterial 131I-L was well tolerated in patients with inoperable hepatocellular carcinoma and produced an objective response of 52% with median survival of 6 mo. A fractionated dose of 131I-L was feasible and the radiation dose could be escalated safely.

Ultrasound-guided tissue-core biopsy of thoracic lesions with Trucut and Surecut needles.

The value of ultrasound-guided tissue-core needle biopsy was assessed in 54 patients with thoracic lesions adjacent to the chest wall. Of these, six were apical and two mediastinal. Biopsy was performed with Trucut or Surecut (modified Menghini) needles in 22 patients, and with both in 32 patients in order to compare the two types of needle. Definitive diagnosis was made in 46 patients (85 percent), of whom 41 had malignancy of various cell types, and five had benign lesions. Of the remaining eight, three had apical lesions, and two had consolidation distal to a proximal tumor. There was complete histologic agreement in 25 of 32 patients where biopsy was performed with both needles. Roentgenographic size of the lesion had relatively little influence on the diagnostic yield. Complications comprise moderate hemoptysis in one patient (2 percent), trivial hemoptysis or hemothorax in three, and symptomless pneumothorax in two which resolved spontaneously. We conclude that tissue core needle biopsy of thoracic lesions under ultrasound guidance is an accurate and safe technique which provides specimens adequate for routine histologic examination. The diagnostic yield from Trucut and Surecut biopsies is comparable.

Treatment of inoperable hepatocellular carcinoma by intra-arterial lipiodol and 4'-epidoxorubicin.

A total of 30 patients presenting with inoperable hepatocellular carcinoma (HCC) were treated with intrahepatic arterial Lipiodol (5 ml) and 4'-epidoxorubicin (90 mg/m2) once every 4 weeks. The treatment results included no complete response, 2 partial responses, 6 cases of static disease and 19 cases of progressive disease. The median survival was 18.9 weeks. All patients had died by the time of this writing, with survival duration ranging from 4.1 to 87.3 weeks. Toxicities were minimal and included anaemia and alopecia. As compared with a historic control group that had received the same dose of intravenous 4'-epidoxorubicin, the treatment group showed similar response rates but developed fewer toxicities. There was no significant survival benefit over the control group. We concluded that although this form of treatment had comparable activity and produced fewer side effects, it provided no survival benefit over intravenous treatment. The slight prolongation of survival achieved in the treatment group as compared with the control arm might have been due to case selection.

Determination of tumour vascularity using selective hepatic angiography as compared with intrahepatic-arterial technetium-99m macroaggregated albumin scan in hepatocellular carcinoma.

A total of 51 patients with hepatocellular carcinoma (HCC) were studied to determine the tumour vascularity as determined by selective hepatic angiography (HAG) and by intrahepatic-arterial technetium-99m-labeled macroaggregated albumin (Tc99m-MAA) scan. The tumour vascularity was graded on the HAG films by an interventional radiologist using a scale ranging from 1 (hypovascular) to 4 (extremely hypervascular). The grades of vascularity on HAG were grade 1 in 5 patients, grade 2 in 13 patients, grade 3 in 24 patients and grade 4 in 9 patients. The tumour vascularity on scintigraphy was determined by quantifying the count rates over the tumour and normal liver areas by an analog/digital gamma-camera, and the resultant tumour-to-normal ratio (T/N ratio) gave a quantitative measure of the vascularity. The range of the T/N ratio was 0.9 to 11.1, with a median of 3.7. There was no correlation between the tumour vascularity grading on HAG and the T/N ratio on the Tc99m-MAA scan (Wilcoxon rank test, P = 0.83). Thus, we conclude that HAG cannot reveal the true vascularity nor reflect the T/N ratio in HCC.

Hepatic intra-arterial lipiodol ultrasound guided biopsy in the management of hepatocellular carcinoma.

One hundred and fifty-one consecutive new patients with suspected hepatocellular carcinoma (HCC) were investigated from 1989 to 1990. Ultrasound showed the tumours to be inoperable in 111 patients. Selective hepatic angiography revealed 17 more patients with inoperable HCC. Hepatic intra-arterial lipiodol (HIAL) was injected in the remaining 23 patients. In 16 of them, a clinical decision could be reached basing on the radiological findings. Hepatic intra-arterial lipiodol ultrasound (HIAL/USG) guided biopsy was done in seven patients with suspicious lesions. Histology obtained with this method revealed hyperplastic cirrhotic nodules in four patients (two with suspected HCC and two with suspected secondaries). In another two patients, the suspected lesions were confirmed to be malignant. In the last patient who had received chemotherapy for extensive HCC, HIAL/USG guided biopsy revealed necrotic tissue only. At laparotomy, diffuse infiltrative abnormality was found and repeated biopsy confirmed residual malignancy in the necrotic tumour. We conclude that when there is radiological uncertainty as to the nature and extent of the HCC, HIAL/USG guided biopsy can help the clinician to make important decisions.

Second branchial cleft cysts: variability of sonographic appearances in adult cases.

BACKGROUND AND PURPOSE: Previous reports have suggested that second branchial cleft cysts (BCCs) appear on sonograms as well-defined, cystic masses with thin walls and posterior enhancement. Previous CT and MR imaging findings, however, have indicated heterogeneity of these masses, and, in our experience, sonography also shows a similar variable appearance. In this communication, we report the cases of 17 patients with second BCCs and document the variability of sonographic patterns. METHODS: The sonograms of 17 adults with second BCCs were reviewed. Only patients with surgical or cytologic evidence of BCCs were included in this study. The features evaluated were the location, internal echogenicity, posterior enhancement, and presence of septa and fistulous tract. RESULTS: Four patterns of second BCCs were identified: anechoic (41%), homogeneously hypoechoic with internal debris (23.5%), pseudosolid (12%), and heterogeneous (23.5%). The majority (70%) showed posterior enhancement. All were situated in their classical location, posterior to the submandibular gland, superficial to the carotid artery and internal jugular vein, and closely related to the medial and anterior margin of the sternomastoid muscle. Fourteen (82%) of the 17 BCCs had imperceptible walls, and all were well defined. For none of the patients was a fistulous tract revealed by sonography; the presence of internal septations was revealed for three patients. CONCLUSION: As previously suggested by CT and MR imaging findings, sonography reinforces that second BCCs in adults are not simple cysts but have a complex sonographic pattern ranging from a typical anechoic to a pseudosolid appearance.

Power Doppler sonography to differentiate tuberculous cervical lymphadenopathy from nasopharyngeal carcinoma.

BACKGROUND AND PURPOSE: Tuberculous lymphadenitis and metastatic nodes from nasopharyngeal carcinoma are common in Asians and are often indistinguishable clinically. Because their treatment depends on prompt diagnosis, we undertook this study to evaluate if power Doppler sonography could distinguish these two pathologic abnormalities. The intranodal vascular appearances of tuberculous neck nodes are compared with benign reactive neck nodes and metastatic nodes from nasopharyngeal carcinoma. METHODS: The appearances of power Doppler sonograms of 42 tuberculous nodes were compared with 28 metastatic nodes from nasopharyngeal carcinoma and 27 benign reactive nodes. The intranodal distribution of vessels and the intranodal vascular resistance of vessels were compared among these three groups. All examinations were performed by the same sonologist (A.A.), who had more than 3 years' scanning experience, and all data analysis was performed by the same investigator (M.Y.). RESULTS: The intranodal vascular distribution in tuberculous nodes was varied and simulated both benign and malignant disease. Avascularity of nodes and displacement of hilar vascularity were frequent in tuberculous nodes. Metastatic nodes from nasopharyngeal carcinoma (resistive index [RI], 0.81+/-0.09; pulsatile index [PI], 1.91+/-0.81) had a higher vascular resistance than did tuberculous nodes (RI, 0.71+/-0.11; PI, 1.34+/-0.55). Tuberculous nodes had a higher vascular resistance than did reactive nodes (RI, 0.66+/-0.09; PI, 1.10+/-0.26). CONCLUSION: Avascularity, displaced hilar vessels, and low intranodal vascular resistance are clues that may suggest the tuberculous nature of neck nodes. However, there is overlap of appearance between tuberculous nodes, benign reactive neck nodes, and metastatic nodes. Thus, histologic analysis is often required for a definitive diagnosis.

Thyroglossal duct cysts: sonographic appearances in adults.

BACKGROUND AND PURPOSE: Previous reports have suggested that thyroglossal duct cysts (TDCs) appear on sonograms as well-defined cystic masses with thin walls and posterior enhancement. In our experience, however, TDCs have a variable sonographic appearance. We report our findings in 40 patients with TDCs and document the variability of sonographic patterns. METHODS: All patients in whom the diagnosis of TDC was made clinically (by at least two head and neck surgeons) and sonography detected a cystic mass related to the hyoid bone were included in this study. Sonograms of 40 patients with TDCs were reviewed. The features evaluated were the location, internal echogenicity, posterior enhancement, presence of septa, solid component, and fistulous tract. The echo pattern was not compared with the biopsy results. RESULTS: Four patterns of TDCs were identified: anechoic (28%), homogeneously hypoechoic with internal debris (18%), pseudosolid (28%), and heterogeneous (28%). The majority showed posterior enhancement (88%), were midline (63%), and infrahyoid in location (83%). Only half of all TDCs showed a typical thin wall. CONCLUSION: On sonograms, TDCs in adults are not simple cysts, as previously suggested, but have a complex pattern ranging from a typical anechoic to a pseudosolid appearance.

CT and MR imaging appearances of an extraosseous calcifying epithelial odontogenic tumor (Pindborg tumor).

We herein report a rare case of extraosseous calcifying epithelial odontogenic tumor with local aggressive behavior. CT and MR imaging showed the distinctive appearances of this histologic entity. We briefly discuss the radiologic features of calcifying epithelial odontogenic tumor and the relevant literature.

Metastatic adenopathy from nasopharyngeal carcinoma: successful response to radiation therapy assessed by color duplex sonography.

BACKGROUND AND PURPOSE: Although the role of gray-scale sonography for neck nodes is well documented, it plays a limited role in the evaluation of nodal response to treatment. This preliminary limited study sought to determine color duplex sonographic changes in successfully treated metastatic nodes from nasopharyngeal carcinoma. METHODS: Fourteen patients with nodal metastases from nasopharyngeal carcinoma were studied. A pretreatment sonogram was obtained for all patients. Patients were divided into two groups of seven: in one group, repeat sonograms were obtained 8 weeks after completion of treatment; in the second group, sonograms were obtained 16 weeks after treatment. The features studied included distribution of intranodal vascularity, resistive and pulsatility indexes, and peak systolic velocity. In 11 patients, follow-up sonograms were obtained 1 year after treatment. RESULTS: The majority (90%) of malignant nodes from nasopharyngeal carcinoma have an increased central and peripheral vascularity, a high resistive index (0.8), and a high pulsatility index (1.8). After radiation therapy to the nodes, a reduction in intranodal vascularity and a statistically significant reduction in the resistive index (0.58 to 0.59) and pulsatility index (0.91 to 0.93) are found. Although a similar reduction in the peak systolic velocity is observed, it is not statistically significant. CONCLUSION: Our preliminary findings suggest that after radiation therapy for malignant nodes in nasopharyngeal carcinoma, a reduction in intranodal vascularity is found, and the resistive and pulsatility indexes may return to benign parameters as early as 8 weeks after completion of treatment.

Head and neck lipomas: sonographic appearance.

PURPOSE: The diagnosis of cervical lipoma may not always be clinically apparent, in which case patients are frequently referred for sonography. The purpose of this study was to document the sonographic features of head and neck lipomas. METHODS: Twenty-five patients with soft-tissue masses in the neck had sonography as their initial imaging study. A lipoma was suspected on the basis of findings at clinical examination in only eight of these patients. Lipoma was confirmed by fine-needle aspiration cytology in 11 patients, by excision biopsy in five patients, by CT in two patients, and by clinical examination with clinical sonographic follow-up (6 months to 2 years) in seven cases. RESULTS: Lipomas were well-defined (88%), compressible (100%), elliptical masses with the longest diameter parallel to the skin surface. All contained multiple echogenic lines parallel to the skin surface with no evidence of posterior enhancement or attenuation and no flow on color Doppler sonography. Compared with adjacent muscle, 76% of all lipomas were hyperechoic, 8% isoechoic, and 16% hypoechoic. CONCLUSION: The characteristic sonographic appearance of head and neck lipomas is that of an elliptical mass parallel to the skin surface that is hyperechoic relative to adjacent muscle and that contains linear echogenic lines at right angles to the ultrasound beam.

Carcinoma showing thymiclike differentiation (CASTLE tumor).

A 67-year-old woman had had a neck mass for 10 years, which recently increased in size. Sonographic, CT, and MR examinations showed a mass in the carotid and posterior spaces (triangle) extending from below the submandibular gland to the supraclavicular fossa, displacing the common carotid artery and the sternomastoid anteriorly. The mass was solid, noncalcified with lobulated outlines, hypoechoic on sonograms, of soft-tissue density on CT scans, isointense on T1-weighted MR images, hyperintense on T2-weighted MR images, and enhanced mildly after injection of contrast material on CT and MR studies. Histologic examination revealed a carcinoma showing thymiclike differentiation, a rare tumor of the neck and thyroid gland.

Madelung disease: distribution of cervical fat and preoperative findings at sonography, MR, and CT.

PURPOSE: Our goal was to document the distribution of excess fat in the neck and to determine the preoperative role of sonography, CT, and MR imaging in patients with Madelung disease. METHODS: Eight patients with Madelung disease were examined preoperatively with sonography, CT, and MR imaging of the neck, and the extent to which each technique provided answers to the surgeons' questions--such as distribution of fat, course of the major vessels within the fat, and presence of tracheal compression and nonlipomatous lesions--was studied. RESULTS: Excess fat was seen predominantly in the posterior part of the neck (eight patients), under the trapezius (eight patients) and sternomastoid (six patients) muscles, in the supraclavicular fossa (five patients), between the paraspinal muscles (five patients), in the anterior part of the neck (suprahyoid in seven patients and infrahyoid in three patients), in the superior mediastinum (three patients), and in the prevertebral space (two patients). Excess fat deposition was also seen in the pretracheal space (one patient), extrapleural space (two patients), and over the cheeks (one patient), sites previously not described. CONCLUSION: As a preoperative investigative tool for Madelung disease, both MR imaging and noncontrast CT provide the surgeon with adequate information; sonography is less helpful.

Intrathyroidal lymphoepithelial (branchial) cyst: sonographic features of a rare lesion.

Intrathyroidal lymphoepithelial cysts are rare, and only 15 such cases have been reported. Although sonography has been performed in some cases, the findings have not been discussed previously. Despite its rarity, the sonographic appearances of this lesion are similar to those of other commonly encountered congenital cystic lesions in the head and neck, such as thyroglossal duct cysts and second branchial cleft cysts, and this may provide a clue to its diagnosis. We describe the sonographic appearances of intrathyroidal lymphoepithelial cysts.