Terms, definitions and measurements to describe sonographic features of lymph nodes: consensus opinion from the Vulvar International Tumor Analysis (VITA) group.

In centers with access to high-end ultrasound machines and expert sonologists, ultrasound is used to detect metastases in regional lymph nodes from melanoma, breast cancer and vulvar cancer. There is, as yet, no international consensus on ultrasound assessment of lymph nodes in any disease or medical condition. The lack of standardized ultrasound nomenclature to describe lymph nodes makes it difficult to compare results from different ultrasound studies and to find reliable ultrasound features for distinguishing non-infiltrated lymph nodes from lymph nodes infiltrated by cancer or lymphoma cells. The Vulvar International Tumor Analysis (VITA) collaborative group consists of gynecologists, gynecologic oncologists and radiologists with expertise in gynecologic cancer, particularly in the ultrasound staging and treatment of vulvar cancer. The work herein is a consensus opinion on terms, definitions and measurements which may be used to describe inguinal lymph nodes on grayscale and color/power Doppler ultrasound. The proposed nomenclature need not be limited to the description of inguinal lymph nodes as part of vulvar cancer staging; it can be used to describe peripheral lymph nodes in general, as well as non-peripheral (i.e. parietal or visceral) lymph nodes if these can be visualized clearly. The association between the ultrasound features described here and histopathological diagnosis has not yet been established. VITA terms and definitions lay the foundations for prospective studies aiming to identify ultrasound features typical of metastases and other pathology in lymph nodes and studies to elucidate the role of ultrasound in staging of vulvar and other malignancies. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

[Tumours of the large bowel and rectum: possibilities and limitations of sonographic evaluation]. / Tumoren des Kolon und Rektum:Möglichkeiten und Grenzen der Sonografie.

PURPOSE: Sonographic detection rate of colorectal tumours in comparison with endoscopy. MATERIALS AND METHODS: Within a period of 32 months all sonographically detected colorectal tumours were registered and the results compared with endoscopic findings within the same period. The patients had no peroral preparation for the sonographic examination which was always performed before coloscopy. RESULTS: The study encloses 521 tumours in 417 patients. The tumours can be subdivided into 181 cancers, 122 polyps > or = 1 cm, 207 polyps < 1 cm and 11 other tumours. 62 % (112/181) of cancers could be detected by sonography, 30 % of stage pTis, pT1 or pT2, 82 % of stage pT3 or pT4. The detection rate was 20 % for polyps > or = 1 cm, but only 2 % for polyps < 1 cm. The majority of larger tumours not detected on sonography (15/18) was located in the rectum and lower sigmoid colon. CONCLUSION: Colorectal cancers of stage T3 and T4 can be detected sonographically in a high percentage of cases. Sonography provides insufficient results in detecting polyps and small cancers, and even larger tumours may be missed especially in the lower sigmoid colon and rectum.

[Sonographic appearances of subcutaneous and cutaneous oedema -- correlation with histopathology]. / Sonographische Erscheinungsbilder von Odemen der Subkutis und Kutis -- Korrelation mit der Histologie.

PURPOSE: To correlate the sonographic findings of tissue oedema with histopathological changes in order to find an explanation for the different sonographic appearances of oedema. MATERIALS AND METHODS: Subcutaneous and cutaneous tissue of the chest wall, the abdominal wall, and the thigh of 4 human cadavers with clinically evident oedema were examined sonographically. A specimen was then taken from each region for histological examination. RESULTS: Twelve cutis-subcutis-regions underwent sonographic-histological correlation. 9 out of 12 subcutaneous regions exhibited a diffusely increased echogenicity. 5 of the 9 regions with increased echogenicity also showed hypoechoic bands (up to 3 mm) within the subcutaneous tissue. Histologically, all of the 9 sonographically altered subcutaneous regions displayed lentiform or band-like optically empty spaces within the connective tissue between lobules of fatty tissue as well as between groups of fat cells within lobules of fatty tissue corresponding to fluid. Hypoechoic stripes at sonography represented very broad bands of fluid. The cutis appeared hyperechoic in all cases. At histology, 9 of 12 cases exhibited uniformly distributed optically empty spaces between connective tissue fibres of the dermis. Dermal thickness corresponded to the degree of oedema. CONCLUSION: Subcutaneous oedema results in diffusely increased echogenicity, which is caused by the difference in acoustic impedance occurring at the edges of numerous bands of fluid. In addition, hypoechoic bands are observed if broad spaces of fluid are present in severe cases. Encased fluid in the dermis is uniformly distributed between connective tissue fibres. Sonographically, the homogenous hyperechoic appearance of normal dermis remains unaltered in cases of oedema, but dermal thickness increases.

Sonography of the salivary glands.

Due to their superficial position, the parotid, the submandibular, and the sublingual glands can be imaged with high-resolution transducers. In acute inflammatory diseases sonography can differentiate between obstructive or non-obstructive sialoadenitis. Abscess formations may be detected and the maturation of the colliquation may be controlled. Abscesses may be punctured under US guidance. In Sjögren's syndrome the sonographic changes correlate with the histological destruction, and in acute forms hypervascularization is found in color Doppler. In fibrotic cases the stimulation-induced hyperemia is impaired. In sialoadenosis inflammatory and tumorous lesions can be ruled out by sonography. Tumors of the salivary glands can be visualized with high sensitivity. Like other imaging methods the specificity in assessment of the histology of a tumor is low. Multilocular lesions, such as sarcoidosis, lymphoma, metastases, or cystadenolymphoma, are discussed. In deep located, malignant tumors or when the tumor cannot be delineated completely, MR or CT are obligatory to delineate the tumor. Sonography enables the diagnosis of cysts or ranulae. The accuracy of sonography in assessment of sialolithiasis is approximately 90%. Non-opaque stones can be visualized, too; however, small stones of less than 2 mm are difficult to detect since the posterior shadow may be missing. The concrements can be differentiated into intraductal or intraglandular stones. Indirect signs, such as ductal dilatations or inflammatory changes, may be found. Pseudotumorous lesions, such as hypertrophy of the masseter muscle, tuberculosis, sarcoidosis, or lymphoepithelial lesions in AIDS, are discussed. In children the main differential diagnosis of salivary gland pathologies are addressed. In many diseases sonography is the first-line imaging modality in assessment of salivary glands.

Benefit for the patient of a teleradiology process certified to meet an international standard.

To guarantee the quality of teleradiology services in Austria we have developed an easy-to-use and continuously re-evaluated teleradiology workflow model. This is based on the quality management model (ISO 9001:2000) of the International Standardization Organization (ISO) and guarantees the quality of the process. From January 2002 to January 2003 we examined 544 emergency teleradiology computerized tomography studies transmitted to the Department of Radiology 2 in Innsbruck. The patients were from the rural hospital of Reutte. In 450 cases (83%) the sending of the written legal final report took less than 1 h. The numbers of mistakes (mostly minor workflow errors) were reduced from 23 errors per month in January 2002 to 9 errors per month in January 2003. The continuous cross-checking of the workflow and the training of the employees involved guaranteed a better standard of teleradiology in our department. Since December 2002, the whole Tyrolean teleradiology process has been ISO 9001:2000 certified.

[Epiploic appendagitis: sonographic findings in 28 cases]. / Spontane Nekrose einer Appendix epiploica: Sonographische Zeichen in 28 Fällen.

AIM: To investigate the sonographic signs of epiploic appendagitis in a larger number of patients and to add new details. PATIENTS AND METHODS: Over a period of approximately 8 years 28 patients were sonographically diagnosed to have epiploic appendagitis. The following sonographic signs were investigated: echogenicity of the lesion; compressibility; shape of the lesion; adherence to the anterior abdominal wall; peripheral rim; central hypoechoic line; thickening of the colonic wall. In 11 of these patients colour Doppler sonography was performed. In addition all 28 patients underwent CT. RESULTS: In 28/28 cases (100 %) a moderately hyperechoic, ovoid, non-compressible mass adjacent to the colon was demonstrated. The mass was surrounded by a hypoechoic rim in 20 cases (71 %) and was fixed to the abdominal wall in 26/28 cases (93 %). Five cases (18 %) revealed a central hypoechoic line, and slight thickening of the colonic wall was visible in 2 cases (7 %). In those cases where colour Doppler sonography was performed, colour flow was absent in the central part of the lesion. In the peripheral zone slightly increased colour flow was demonstrable in 9/11 cases. CONCLUSION: Epiploic appendagitis has a characteristic sonographic appearance with a moderately hyperechoic, ovoid, non-compressible lesion adjacent to the colon and adherent to the abdominal wall. The mass is frequently surrounded by a hypoechoic rim. Colour Doppler sonography shows a central avascular area and slightly increased colour flow in the peripheral zone.

Colonic diverticulitis: diagnostic value and appearance of inflamed diverticula-sonographic evaluation.

Acute bowel inflammation frequently originates from thin-walled diverticula of the colon. Not the presence of diverticula, but the demonstration of an inflamed diverticulum, is diagnostic of diverticulitis in cases of bowel wall thickening and pericolic inflammation. The aim of this study was to investigate the sonographic appearance and detectability of inflamed diverticula. One hundred seventy-five consecutive patients with clinically suspected diverticulitis underwent sonographic examination. Outpouchings from the colonic wall centred in the pericolic inflammation were considered inflamed diverticula. Depending on the sonographic appearance they were divided into four groups: hypoechoic; predominantly hyperechoic; hyperechoic with surrounding hypoechoic rim; and hyperechoic with acoustic shadowing. Sonography showed inflamed diverticula in 79 (77%) of 102 patients with diverticulitis. Inflamed diverticula were hypoechoic in 37%, predominantly hyperechoic in 4%, hyperechoic with surrounding hypoechoic rim in 41% and hyperechoic with acoustic shadowing in 18% of patients. In 23 (23%) of 102 patients no inflamed diverticulum was demonstrable. This group included 17 patients with complicated diverticulitis and 6 false-negative cases. An inflamed diverticulum as a sign of diverticulitis yielded an overall sensitivity of 77% and a specificity of 99%. Sensitivity in uncomplicated disease was 96%. In patients with uncomplicated diverticulitis an inflamed diverticulum is a sign of diverticulitis with excellent sensitivity and specificity, usually with solitary and less frequently with more than one inflamed diverticulum being demonstrable. In patients with complicated diverticulitis an inflamed diverticulum is often not detectable.

Abdominal wall hernias: cross-sectional imaging signs of incarceration determined with sonography.

OBJECTIVE: The aim of this study was to determine with sonography whether distinct cross-sectional imaging signs exist that may differentiate between incarcerated and nonincarcerated abdominal wall hernias. SUBJECTS AND METHODS: The sonographic appearance of 149 consecutive abdominal wall hernias was prospectively investigated and correlated with subsequent surgical results. Commercially available 4- to 10-MHz linear transducers and 2- to 5-MHz curved transducers were used to evaluate the hernias. RESULTS: Surgery revealed 126 nonincarcerated and 23 incarcerated hernias. The sonographic signs suggestive of incarceration that we identified included free fluid in the hernia sac, which was observed in 91% of the incarcerated hernias and in 3% of the nonincarcerated hernias; bowel wall thickening in the hernia, which was detected in 88% of the incarcerated hernias and in none of the nonincarcerated hernias; fluid in the herniated bowel loop, which was detected in 82% of the incarcerated hernias and in 3% of the nonincarcerated hernias; and dilated bowel loops in the abdomen, which occurred in 65% of the incarcerated hernias and in none of the nonincarcerated hernias. These imaging findings allowed the identification of incarceration in all 23 cases and led to a false-positive result in two of 126 nonincarcerated hernias. CONCLUSION: Cross-sectional imaging signs indicating hernial incarceration included free fluid in the hernial sac, bowel wall thickening in the hernia, fluid in the herniated bowel loop, and dilated bowel loops in the abdomen. Sonography is an appropriate cross-sectional imaging modality for detecting these signs that are helpful in diagnosing patients with atypical clinical presentations.

Reproducibility of lymphoscintigraphy in cutaneous melanoma: can we accurately detect the sentinel lymph node by expanding the tracer injection distance from the tumor site?

UNLABELLED: The aim of the study was to determine whether the sentinel lymph node (SLN) can be accurately detected in cutaneous melanoma patients when the injection distance from the tumor site is expanded. METHODS: In 100 patients with cutaneous melanoma, lymphoscintigraphy was performed twice. First, we injected 37 MBq (99m)Tc nanocolloid intracutaneously at a 2- to 5-mm distance from either the melanoma or the biopsy scar. The injection was followed by dynamic imaging, which continued until the SLN became visible. On another day, we repeated the investigation, injecting the radiopharmaceutical intracutaneously exactly 10 mm from the previous injection site. The detected SLNs of both investigations were compared to determine the number and location of SLNs for each patient. RESULTS: The SLN identification rate was 94% with close injection and 100% with 10-mm-distant injection. All SLNs detected with close injection were visible with distant injection. In 84 of 100 patients, the images of both investigations showed the same number and location of SLNs. In the remaining 16 patients, an additional SLN was detected with the distant injection. CONCLUSION: The reproducibility of lymphoscintigraphy using different injection distances was 84%. The discordance in the remaining 16% was caused by detection of a lymph node in addition to the original SLN with distant injection. Diagnostic excision of the primary tumor before lymphoscintigraphy was possible without preventing detection of the original SLN. However, in 16% of our patients, excision of an additional lymph node had to be considered when lymphoscintigraphy was performed after diagnostic excision.

Suture granulomas: sonography enables a correct preoperative diagnosis.

The purpose of this study was to examine if suture granulomas display distinct sonographic signs and if these signs enable an accurate preoperative diagnosis. In a retrospective and prospective study, the sonographic findings of 22 consecutive suture granulomas were investigated and correlated with subsequent operative results. The sonographic appearance of various surgical sutures in a water bath was also investigated. Sonography was performed with commercially available 5- to 13-MHz linear transducers. The sonographic findings of the suture granulomas included hypoechoic lesions in all cases and hyperechoic double or single lines within the hypoechoic lesions in 20 of 22 cases. Sonography enabled the correct preoperative diagnosis for the investigating radiologists in 20 cases. The sonographic appearance of sutures in a water bath was that of hyperechoic double or single lines. The sonographic signs of suture granulomas (hyperechoic double or single lines within hypoechoic lesions) indicate the correct preoperative diagnosis in a high percentage of cases.

Outer diameter of the vermiform appendix as a sign of acute appendicitis: evaluation at US.

PURPOSE: To evaluate the usefulness and limitations of the outer diameter of the vermiform appendix at cross-sectional ultrasonography to confirm or rule out acute appendicitis. MATERIALS AND METHODS: In a prospective study, outer appendiceal diameters in 240 control subjects and in 278 patients suspected of having acute appendicitis who did (n = 98) or did not (n = 180) have acute appendicitis were measured. RESULTS: Outer appendiceal diameters in the control subjects ranged between 2 and 13 mm, and in 55 (23%) of 240 control subjects, diameters were 6 mm or more. Diameters in the symptomatic patients without acute appendicitis ranged between 2 and 11 mm, and 57 (32%) of 180 patients had diameters of 6 mm or more. Diameters of acutely inflamed appendices ranged between 6 and 30 mm. A diameter of 6 mm or more confirmed acute appendicitis with a sensitivity of 100%; a specificity of 68%; positive and negative predictive values of 63% and 100%, respectively; and an accuracy of 79%. CONCLUSION: The outer appendiceal diameter of 6 mm or more as a sign of acute appendicitis provides high sensitivity but limited specificity. This diagnostic criterion is more useful in excluding acute appendicitis than in confirming it.

Sonography of the thyroid and parathyroid glands.

Sonography is the first line modality for assessment of thyroid and parathyroid pathologies. Sonographic and color Doppler patterns of diffuse and focal pathologies of the thyroid are presented in this article. The accuracy of sonography in the localization of enlarged parathyroid glands is also discussed. The limitations of sonography in specifying focal thyroid diseases and the problems in localizing ectopic parathyroid adenoma are addressed.

Sigmoid diverticulitis: value of transrectal sonography in addition to transabdominal sonography.

OBJECTIVE: Overlying intestinal gas often impairs transabdominal sonographic assessment of the lower sigmoid colon. The aim of this study was to investigate the usefulness of transrectal sonography in addition to transabdominal sonography for the evaluation of sigmoid diverticulitis. SUBJECTS AND METHODS: Eighty-six consecutive patients with clinically suspected acute sigmoid diverticulitis were referred for transabdominal sonography as the initial imaging method. In 46 patients, transrectal sonography was performed in addition to transabdominal sonography if pain was localized to the mid lower abdomen and if a disease process could not be visualized or could be only partially visualized on transabdominal examination. An end-firing 5-9-MHz endocavitary probe was used for transrectal sonography. RESULTS: Thirty-four of 50 patients with a final diagnosis of sigmoid diverticulitis underwent both transabdominal and transrectal sonography. In 20 patients, transrectal sonography showed relevant additional information: six diagnoses of diverticulitis were established on transrectal sonography alone. Transrectal sonography revealed one perforation, five abscesses, and three fistulous complications that were not shown on transabdominal sonography. In the remaining five patients, correct diagnoses were supported on transabdominal examinations, but only transrectal sonography could show an inflamed diverticulum. In 10 patients, transrectal sonography revealed signs of diverticulitis but no relevant information in addition to the results from transabdominal sonography. Four false-negative and two false-positive results were revealed with transrectal sonography. CONCLUSION: Transrectal sonography is accurate for confirming clinically suspected acute colonic diverticulitis when the lower sigmoid colon is affected. It helps avoid false-negative results and defines the severity of disease in the lower sigmoid colon better than transabdominal sonography alone. Transrectal sonography can increase the sensitivity of sonography for diagnosing sigmoid diverticulitis.

[Sonographic diagnosis of thrombosis of the calf muscle veins and the risk of pulmonary embolism]. / Sonographische Diagnose von Muskelvenenthrombosen des Unterschenkels und deren Bedeutung als Emboliequelle.

AIM: To determine the frequency of deep vein thrombosis in the veins of the calf muscles. The risk of embolism in relation to the localisation of thrombosis was also evaluated. METHOD: 357 consecutive patients submitted for colour Doppler sonography of the lower extremities were prospectively examined for deep vein thrombosis (DVT). Both axial and muscular calf veins were investigated. 184 of these patients underwent additional investigation for pulmonary embolism. RESULTS: Diagnosis of DVT was made by means of colour Doppler sonography in 179 patients. Soleal veins (n = 88), peroneal veins (n = 84), the popliteal vein (n = 69), and the superficial femoral vein (n = 53) were the most common sites of thrombosis. Thrombosis of the gastrocnemial veins (n = 49) occurred less frequently. 85 patients (47% of all patients having DVT) showed isolated calf vein thrombosis, in 45 patients (25%) the gastrocnemial and/or soleal veins were the only site of thrombosis. 60% of patients with symptomatic DVT also had pulmonary embolism. The embolic frequency for isolated calf vein thrombosis and muscular calf vein thrombosis was 48% and 50%, respectively. CONCLUSION: The veins of the calf muscles are a common site of acute DVT and a source of pulmonary embolism. They should always be investigated in patients with suspected DVT of the calf, and in patients with pulmonary embolism.

Presence or absence of gas in the appendix: additional criteria to rule out or confirm acute appendicitis--evaluation with US.

PURPOSE: To investigate whether the presence or absence of gas in the appendix may be considered as additional ultrasonographic (US) criteria to rule out or confirm acute appendicitis. MATERIALS AND METHODS: The appendices in 239 control subjects, 138 patients with lower right quadrant pain without acute appendicitis, and 80 patients with acute appendicitis were prospectively evaluated for intraluminal gas with US. RESULTS: The appendices in 206 (86%) control subjects showed gas at US, and those in 33 (14%) did not. The appendices in 109 (79%) symptomatic patients without acute appendicitis showed gas, and those in 29 (21%) did not. The appendices in 12 (15%) patients with acutely inflamed appendices showed gas, and those in 68 (85%) did not. The absence of gas as a criterion for acute appendicitis had a sensitivity of 85%; specificity, 79%; positive and negative predictive values, 57% and 94%, respectively; and accuracy, 81%. Gas was useful to exclude acute appendicitis in 64 (46%) symptomatic patients because the established criteria were misleading. In 19 (24%) patients, the absence of gas was useful for diagnosis of acute appendicitis because the other criteria were not convincing. CONCLUSION: US-based detection of gas in the appendiceal lumen helps to rule out acute appendicitis, whereas the absence of gas further confirms its presence, especially in cases where established US criteria are either insufficiently present or misleading.

Three-dimensional targeting: a new three-dimensional ultrasound technique to evaluate needle position during breast biopsy.

OBJECTIVE: To evaluate the role of three-dimensional (3D) ultrasound (US) following needle breast biopsy under two-dimensional (2D) needle guidance. METHODS: A total of 188 core-needle biopsies and 24 fine-needle aspiration biopsies were 3D US correlated after typical 'freehand' US needle guidance. All cases were examined with a linear 3D US volume scanner (5-13 MHz, Voluson 530D, Medison-Kretztechnik, Zipf, Austria). After core-needle stroke or localization of fine needle, a 3D US data volume set was acquired and a multiplanar analysis performed. This needle position check in all three planes is called '3D targeting'. 66 women with a mean age of 51 years (range, 27-80 years) showed 77 breast lesions (55 solid lesions, 22 cysts) with a mean diameter of 1.5 (range, 0.3-5.0) cm. RESULTS: In 49 women with 55 solid breast lesions, 16 lesions were malignant and 39 lesions benign. In 53 solid breast lesions 188 core-needle biopsies were performed (mean 3.6 biopsies/lesion). After core-needle biopsy 23 lesions (16 malignant, seven benign) were surgically removed. In 22 cases final histology confirmed results of the core-needle specimen. In one case a core-needle specimen of a 5 mm lesion showed atypical lobular hyperplasia. The definitive histology after surgery was invasive lobular carcinoma. Twenty-two cysts and two benign solid lesions were punctured with a fine needle followed by aspiration biopsy. The overall sensitivity of core-needle results in this study was 94% (specificity 100%, accuracy 0.98, positive predictive value 1, negative predictive value 0.97). In 117 core-needle strokes of benign (21) and malignant (12) lesions 3D targeting prospectively revealed 95 lesion hits, Twelve marginal lesion hits and nine out-of-lesion hits. In one case after the initial large core-needle path a 5-mm lesion was disguised by air bubbles, therefore 3D targeting failed during the second biopsy procedure. CONCLUSION: 3D US combined with 3D targeting technique is a reliable and objective tool demonstrating exact spatial positioning of core and fine needle during biopsy procedure.