Ultrasonography of Superficial Soft-Tissue Masses: Society of Radiologists in Ultrasound Consensus Conference Statement.

The Society of Radiologists in Ultrasound convened a panel of specialists from radiology, orthopedic surgery, and pathology to arrive at a consensus regarding the management of superficial soft-tissue masses imaged with US. The recommendations in this statement are based on analysis of current literature and common practice strategies. This statement reviews and illustrates the US features of common superficial soft-tissue lesions that may manifest as a soft-tissue mass and suggests guidelines for subsequent management.

US of the ovary and adnexa: to worry or not to worry?

Ultrasonography (US) is typically the first study to be requested in patients with clinical findings that may suggest pelvic disease. The evaluation of adnexal masses is a common component of the sonologist's workload, and US has been shown to be accurate for both detecting and characterizing these masses, most of which are either insignificant or benign and therefore require little or no follow-up. Recognition of the most common benign ovarian and extraovarian adnexal masses should help avoid additional or unnecessary imaging. US features that suggest malignancy include thick septations, vascularized solid components, or areas of focal wall thickening, and identifying these features will result in timely management. Indeterminate-appearing masses demonstrate atypical features and cannot easily be classified as definitely either benign or malignant. Proper reporting and management recommendations serve to alleviate both patient anxiety and physician misinterpretation. Knowledge of these recommendations and of the characteristic US features of benign, malignant, and indeterminate adnexal masses can serve as important guidelines for patient management.

The CIRAS study: a case control study to define the clinical, immunologic, and radiographic features of aromatase inhibitor-induced musculoskeletal symptoms.

Aromatase inhibitors (AIs) are widely prescribed for post-menopausal hormone receptor-positive breast cancer; however, musculoskeletal symptoms limit their tolerability. The purpose of this study was to determine whether joint pain in women receiving AIs is associated with inflammatory arthritis as measured by the disease activity score-28 (DAS-28), and to evaluate association with tenosynovitis on ultrasound. A total of 48 postmenopausal women with stage I-III breast cancer and hand pain were recruited from the Lombardi Comprehensive Cancer Center. Those receiving AIs were cases (n = 25), and those not receiving AIs were controls (n = 23). During a single study visit, subjects underwent blinded rheumatologic evaluation, DAS-28, health assessment questionnaires, autoantibodies, inflammatory markers, hand X-ray, and hand Duplex ultrasound. There were no significant differences between cases and controls in DAS-28, or inflammatory markers. A positive ANA (titer > 1:160) was found in ten patients, four of whom met criteria for autoimmune disease (two with rheumatoid arthritis and two with Sjogren's syndrome, equally distributed among cases and controls). This highlights the importance of considering underlying autoimmune disease in subjects with musculoskeletal complaints. Morning stiffness was more prolonged in women receiving AIs, but this did not reach statistical significance (P = 0.07). Ultrasound evidence of flexor tenosynovitis was common in both groups. Although tenosynovitis was not correlated with AI use (P = 0.26), there was a trend toward an association between tenosynovitis and morning stiffness (P = 0.089). While aromatase inhibitor-induced musculoskeletal symptoms (AIMSS) were more common in subjects receiving AIs, they were not unique to AI users. There was no association between presence of AIMSS features and other chemotherapy or medication exposures. Although the majority of subjects had been using AIs for more than 6 months, this study did not find evidence for inflammatory arthritis in women with hand pain receiving AIs. Further studies are needed to develop a case definition of AIMSS, and to confirm whether these symptoms are attributable to AI use.

saline-infused sonohysterography: tips for achieving greater success.

Saline-infused sonohysterography (SIS) may help improve visualization of the endometrium and endometrial cavity and assess tubal patency. Although most SIS procedures are straightforward, a variety of pitfalls may lead to an unsuccessful procedure or incomplete evaluation. SIS should be scheduled between days 4 and 10 of the patient's menstrual cycle, when the endometrium is at its thinnest, and physiologic changes during the secretory phase are not present. Performing preprocedure imaging serves many purposes, such as depicting hydrosalpinx, causes of uterine and adnexal tenderness, and pelvic inflammatory disease, as well as assessing the size and position of the uterus and the orientation of the cervix. It is important not to presume that fibroids are the cause of bleeding when the endometrium is obscured at preprocedure imaging. Obstacles to a successful procedure include issues related to patient anxiety and discomfort, which may be prevented or minimized at almost every step of the procedure. Inability to obtain access to the cervix is the most common cause of unsuccessful SIS; proper patient positioning in a semi-upright lithotomy position is important. Injection of air during any US-guided procedure may lead to shadowing that obscures the region of interest. Adequate distention of the endometrial cavity is crucial for successful SIS, and optimal positioning of the distended balloon may improve the degree of distention. However, poor distention may be indicative of an underlying pathologic condition. Knowledge of these pitfalls and the strategies to overcome them may prevent premature or unnecessary termination of an otherwise successful study.

Musculoskeletal ultrasound: evaluation of the finger.

OBJECTIVE: Ultrasound is well suited for evaluating the superficial structures of the finger. The purpose of this video article is to review basic anatomy, scanning techniques, and sonographic appearance of the tendons, pulleys, and ligaments of the finger. Examples of pathologic conditions that can affect these structures will be shown. Please note that the large size of this file may result in several minutes of download time. CONCLUSION: Ultrasound is an established safe, efficient, and cost-effective method to evaluate structures in the finger. Knowledge of anatomy and technique is essential for scanning the finger accurately and effectively. The dynamic capability of ultrasound is especially helpful in evaluating for tendon and pulley injury and pathology.

Musculoskeletal ultrasound: evaluation of ankle tendons and ligaments.

OBJECTIVE: Ultrasound is well-established as a safe, efficient, and cost-effective method to evaluate superficial structures about the ankle. The purpose of this video article is to review the anatomy, scanning techniques, and sonographic appearance of the tendons and ligaments of the ankle. CONCLUSION: Ultrasound is well-suited for imaging the tendons and ligaments of the ankle. Knowledge of anatomy and bony landmarks is essential for scanning the ankle accurately and efficiently.

Trp-49 of the family 3 beta-glucosidase from Aspergillus niger is important for its transglucosidic activity: creation of novel beta-glucosidases with low transglucosidic efficiencies.

Family 3 beta-glucosidases from Aspergillus niger with substitutions for Trp-49 result in the accumulation of very small amounts of transglucosidic adducts, compared to the large amounts that accumulate with wild type enzyme. On the other hand, the amounts of the hydrolytic products that form is decreased by only small amounts. Kinetic studies showed that the main reason for the decreased accumulation of transglucosidic intermediates is a large decrease in binding capacity for Glc at site +1 and an increase in binding ability at site-1. The hydrolytic catalytic constants (kcat(h)) of the substituted enzymes were 3 to 4-fold smaller than those of wild type enzymes, while the Km(h) values were less than 2-fold smaller. The catalytic constants of the transglucosidic reactions (kcat(t) values) were essentially unchanged, but the Km(t) values of the substituted enzymes were about 25-fold larger than those of wild type enzymes. These changes mean that the efficiencies of hydrolytic reactions (kcat(h)/Km(h)) of beta-glucosidases created through substitutions for Trp-49 are less than 2-fold smaller than those of wild type beta-glucosidase, but the efficiencies of the transglucosidic reactions (kcat(t)/Km(t)) of the substituted enzymes are 25 to 30-fold smaller. This results in a significantly decreased formation of transglucosidic intermediates. In addition, the high hydrolytic efficiencies of the substituted enzymes, cause even the very small amounts of transglucosidic intermediates that form to be rapidly hydrolyzed. The overall effect is a very small accumulation of intermediates.

MRI of adenomyosis: changes with uterine artery embolization.

OBJECTIVE: Our objective was to describe the MRI features of patients with pure or dominant adenomyosis treated with uterine artery embolization (UAE) and to correlate imaging features with symptoms. SUBJECTS AND METHODS: Nineteen patients with symptomatic pure or dominant adenomyosis on MRI were referred for UAE. All 19 patients had repeat MRI 4 months after UAE. The MR images obtained before and after UAE were evaluated for maximal junctional zone thickness, junctional zone-myometrial ratio, uterine volume, and the presence of avascular regions. Patients were asked to complete a questionnaire about their symptoms before and 3 and 12 months after UAE. RESULTS: Uterine volume decreased significantly after UAE (p < 0.01). The mean uterine volume reduction was 25.1%. Junctional zone thickness decreased significantly (p < 0.001). The junctional zone-myometrial ratio did not decrease significantly (p = 0.526). Fourteen (73.7%) of the 19 patients showed devascularized change within the adenomyotic region. Eighteen patients completed a questionnaire at 3 months. Sixteen (88.9%) of the 18 reported an improvement in symptoms, whereas the two remaining patients (11.1%) reported no change (p < 0.001). Of the 16 patients with clinical improvement, 11 had devascularized areas after UAE and five did not. Eleven of the 18 patients who completed a questionnaire 3 months after UAE also completed a questionnaire 12 months after UAE. Ten of these 11 patients still reported continued improvement, and one patient reported a worsening of symptoms. CONCLUSION: UAE in patients with pure or dominant adenomyosis results in decreased uterine volume and regions of devascularization. Most patients reported an improvement in clinical symptoms within 3 months after UAE. Some patients reported benefit for at least 1 year; however, the long-term durability of symptomatic relief remains unknown.

Imaging manifestations of complications associated with uterine artery embolization.

Uterine artery embolization (UAE) is an increasingly performed, minimally invasive alternative to hysterectomy or myomectomy for women with symptomatic uterine fibroids. A growing body of literature documents symptomatic improvement in the majority of women who undergo UAE. Although UAE is usually safe and effective, there are a number of known complications associated with the procedure. Major complications include fibroid passage, infectious disease (endometritis, pelvic inflammatory disease-tubo-ovarian abscess, pyomyoma), deep venous thrombosis, pulmonary embolism, inadvertent embolization of a malignant leiomyosarcoma, ovarian dysfunction, fibroid regrowth, uterine necrosis, and even death. Minor complications include hematoma, urinary tract infection, retention of urine, transient pain, and vessel or nerve injury at the puncture site. As UAE takes its place in the treatment arsenal for women with symptomatic fibroids, radiologists need to be familiar with UAE-associated complications, which may require further treatment and may even be life threatening in some cases. Knowledge of these complications and their imaging features should lead to prompt diagnosis and appropriate treatment.