Echogenic Lesions Research Articles

PP-207. Evidence of oxidative stress in Beckwith Wiedemann Syndrome by measuring a redox biomarkers profile

able. Pregnancy was unmarked but an increased need for assisted delivery after vaginal birth took place. Clinical findings included neonatal hypotonia, altered consciousness (lethargy), dolichocephaly, and bilateral cryptorchidismwithout any other signs of systemic illness. The newborn had decreased spontaneous movements and arousal, a weak cry, poor suck (need for tube feeding), and poor reflexes. Cranial ultrasound showed a temporal bilateral echogenic lesion. MRI of the head confirmed a diagnosis of extensive thrombosis of cerebral sinuses (CSVT) with a partial occlusion of superior sagittal sinus, torcular, transverse and sigmoid sinuses with no parenchymal brain lesion. A detailed hemostatic screening for hypercoagulable states was normal. Because of persistent and unexplained hypotonia Prader-Willi syndrome(PWS)was suspected.Methylation analysis confirmed PWS. FISH analysis excluded a deletion in 15q11-q13 and maternal uniparental disomy (UPD) for chromosome 15 was confirmed. Treatment consisted of rehydration and systemic anticoagulation with LMWH in a therapeutic anti-X level. The hypotonia gradually improved after the acute phase and the neonate was discharged at 28 days of life. On a follow up examination at 2 months of age, MR venography (MRV) revealed a remarkable reduction of thrombus size.

Pathologic basis of echogenic cystic lesions in the human placenta: Role of ultrasound-guided wire localization

Objective The sonographic appearance of the placenta is normally homogenous throughout the second trimester. A variety of abnormalities in placental texture have been described, some of which may be pathologic and associated with adverse clinical outcomes. We characterized the pathologic basis of one lesion termed echogenic cystic lesions (ECLs) that may be a prognostic marker in intrauterine growth restriction (IUGR). Study design We retrospectively correlated placental pathology in 50 pregnancies that had a total of 84 ECLs documented by ultrasound prior to delivery. Six additional women with placental ECLs prospectively underwent immediate post-delivery ultrasound-guided wire localization of 9 lesions followed by placental pathology. Obstetric outcome data were recorded. Results Severe pre-eclampsia (20%) and extreme IUGR (18%) were common outcomes. Of 93 ECLs identified, 46 (49%) gross lesions were found by placental pathology. Inter-villous thrombosis was the most significant lesion found (30/46, 65%) compared to all other lesions (35%; Z-Test, p = 0.007). Ultrasound guidance identified 8/9 (89%) lesions of which 6/8 (67%) were inter-villous thrombosis. Associated lesions (infarction, 36%; advanced villous maturation, 27%) and small placental weight (<10th centile, 38%) were present in 50%, but did not increase the risk of adverse perinatal outcome. Conclusions ECLs are most commonly due to inter-villous thrombosis. The adverse clinical outcomes may be mediated by associated lesions not readily detectable by ultrasound. Ultrasound-guided wire localization is a promising research tool for future large-scale cohort studies needed to define the clinical utility of placental ultrasound findings.

Endoscopy and endoscopic ultrasonography for heterotopic pancreas in upper gastrointestinal tract

Objective To study the characteristics of heterotopic pancreas （HP） in upper gastrointestinal tract （UGIT） under endoscopy and endoscopic sonography （EUS）, and its endoscopic manage- ments. Methods Data of 67 patients with pathologically confirmed HP in our hospital from March 2004 to November 2009, including clinical and endoscopic manifestations and sequelae after endoscopic resection, were retrospectively studied. Results Heterotopic pancreas were most commonly found as a single lesion in gastric antrum （62/67, 92. 5% ） and in gastric angle and duodenum as well, which were characterized by protrusion, with intact mucous membrane and centrally umbilicated. Of the 67 patients, 59 underwent EUS before endoscopic resection. Findings were heterogeneous and mixed echogenic lesions with indistinct borders involving both the second and third layers of the gastrointestinal wall, sometimes even involving the first and fourth layers. Most lesions （n = 60） were removed by endoscopic mucosal resection （EMR） , with basal res- idues in 25 eases, in which fourth layer involvement was observed in 23 cases （92. 0% ）. Delayed bleeding occurred in 1 case at 3rd day after the procedure, and no other complications were observed. Complete re- moval was achieved in 8 cases （including one receiving EMR previously） with endoscopic submucosal dis- section （ESD） , and there was no such severe complications as perforation. Postoperative pathological exami- nations revealed that the consistent rate of preoperative diagnosis with EUS was 91.5% （54/59）. Conclu- sion Endoscopy combined with EUS is critical in diagnosis of HP in UGIT. EMR, especially with cap assistance, is the best method for those without involvement of muscularis propria, while ESD or endoscopic surveillance is a better alternative for those with 4th layer involvement. Key words: Pancreatic diseases ; Endoscopic uhrasonography ; EMR ; ESD

A rare cause of left upper quadrant abdominal pain

Dr. Fiorentino: A 44-year-old black woman from Cuba was admitted to the Emergency Department (ED) because of stabbing abdominal pain in the left upper quadrant, which had begun suddenly after she finished working. During the week prior to admission, she had no fever, no symptoms or signs of gastroenteritis, no dysuria, and no change in bowel habit. The patient said that she had the same symptoms 2 years prior to this episode after an airplane flight. On that occasion, she was admitted to a hospital, but she did not remember the diagnosis and no records were available. The patient also had no recollection of previous diagnosis of hemoglobinopathies, was not aware of previous health problems or diseases and had no recollection of childhood hospitalization. On admission to the ED, she presented symptomatic with mild tenderness in the left upper quadrant of the abdomen. The vital signs were: pulse 93 beats/min, respiratory rate (RR) 16 breaths/min, blood pressure (BP) 130/85 mmHg, body temperature 36.7 C. The finger stick glucose was 91 mg%. The 12-lead ECG showed a sinus rhythm with a normal QRS shape. Physical examination revealed a soft abdomen that was mildly tender in the left upper quadrant. There were no pulsating masses, no splenomegaly, no asymmetrical peripheral pulses nor detectable bruits. The liver was slightly enlarged on palpation. The remainder of the examination was unremarkable. The results of routine laboratory findings, including b-HCG, ALT, AST, pancreatic amylase, bilirubin, creatinine, coagulation parameters were within normal range, except for a mild anemia (Hb = 11.2 g/dl; Htc = 33.4%; VCM = 80.5 fl), mild LDH (903 U/L) and PCR increase (3.29 mg/dl) [1, 2]. The ultrasound (US) abdominal examination [3] revealed an abnormal and inhomogeneous splenic echostructure because of multiple lesions, with the characteristics of ischemic infarctions and scarring (Fig. 1, see white arrows); there were no other pathological findings in the liver, kidneys, pancreas, abdominal aorta and pelvic organs. Acute splenic infarctions appear as more or less echogenic lesions, without Doppler signal (Fig. 2; see white arrows), with variable dimensions, that extend to the surface. Their characteristic pyramidal shape allows us to distinguish splenic infarction from abscesses or tumoral infiltration. The chronic relapsing infarction is typical of sickle cell anemia. In this case, the spleen has multiple echogenic or hypoechoic focal lesions that led to a progressive splenic capsule retraction because of fibrous scars. During recovery there is an increase in echogenicity and the retraction of the infarcted area. The complications (20% of all cases) are [4]: gradual colliquation (degeneration of splenic tissue to a liquid state after a necrotic process), sub-capsular bleedings, pseudoaneurysms or arterio-venous fistulae and hemoperitoneum. The possible evolutions are:

Sonographic appearance of gestational trophoblastic disease evolving into epithelioid trophoblastic tumor

Epithelioid trophoblastic tumor is a distinctive but rare trophoblastic tumor. It derives from intermediate trophoblastic cells of the chorion laeve and is usually associated with a previous gestational event. We report the case of a patient who had undergone dilatation and curettage for a missed miscarriage. Three months later gestational trophoblastic disease was suspected because of persistent vaginal bleeding and high levels of beta-human chorionic gonadotropin (beta-hCG). Transvaginal ultrasound revealed irregular echolucent lacunae within the myometrium, some of them filled with low-resistance, turbulent blood flow on Doppler examination, emphasizing the diagnosis of gestational trophoblastic disease. The patient was treated with 12 courses of multiagent chemotherapy. After a 2-year remission, a low rise in serum beta-hCG was observed. Transvaginal ultrasound revealed a well-circumscribed echogenic lesion with a diameter of 1.8 cm in the uterine fundus, with no detectable blood flow on Doppler imaging. A diagnosis of tumor of intermediate trophoblastic cells was suspected and total hysterectomy was performed. On pathological examination, the histological and immunohistochemical features were characteristic of epithelioid trophoblastic tumor. Most reported cases of epithelioid trophoblastic tumor have solitary nodules with sharp margins, which is consistent with our ultrasound findings. Ultrasound may be helpful in differentiating epithelioid trophoblastic tumor from placental-site trophoblastic tumor, another tumor of intermediate trophoblastic cells, which shows infiltrative growth insinuating between muscle fibers.

FDG Uptake in Fat Necrosis Following Transverse Rectus Abdominis Myocutaneous (TRAM) Flap Reconstructed Breasts

We describe 3 cases of fat necrosis with increased FDG uptake in patients with breast cancer who underwent mastectomy and then transverse rectus abdominis myocutaneous (TRAM) flap reconstruction. PET/CT performed for restaging showed focal FDG uptake in the reconstructed breast. The FDG uptake corresponded to irregular fibrotic nodular lesions containing fat density or calcification in accompanying CT images. Subsequent ultrasound examination demonstrated ill-defined echogenic lesions with internal hypoechoic components. Fat tissue rich flap used for breast reconstruction may be injured by surgical manipulation. Abnormal FDG uptake in this setting is most likely due to fat necrosis, rather than recurrent tumor.

Pseudoenhancement Within the Local Ablation Zone of Hepatic Tumors Due to a Nonlinear Artifact on Contrast-Enhanced Ultrasound

Pseudoenhancement of an avascular region on contrast-enhanced ultrasound often occurs within an echogenic region of a radiofrequency ablation zone due to nonlinear ultrasound propagation through intervening microbubble-perfused tissue. The purpose of this study was to describe the imaging features of this artifact. Twenty-six patients with no tumor recurrence within ablation zones were included. Two radiologists assessed contrast-enhanced ultrasound pseudoenhancement in the arterial (< 30 seconds), portal (30-90 seconds), and late (> 90 seconds) phases. If pseudoenhancement was present, the following information was recorded: the degree, time to first appearance, progression over time, and location. The corresponding gray-scale echogenicity (hypo-, iso-, or hyperechoic) and lesion depth were also noted. Fourteen lesions (14/26, 54%) showed pseudoenhancement on contrast-enhanced ultrasound. Fourteen (100%) corresponded to the hyperechoic area within the ablation zone on gray-scale ultrasound and were nonmarginal in location. Pseudoenhancement occurred more frequently in deep lesions (> or = 5 cm) than in superficial lesions (< 5 cm) (p = 0.002). Pseudoenhancement was initiated most frequently in the portal phase (9/14, 64%), followed by the arterial phase (4/14, 29%) and late phase (1/14, 7%). Progression in the degree of pseudoenhancement was shown in most cases (12/14, 86%) and no washout was seen. Pseudoenhancement is frequently seen within ablation zones on contrast-enhanced ultrasound, particularly in deep echogenic lesions. However, pseudoenhancement follows enhancement of the parenchyma between the transducer and target. This observation is consistent with nonlinear propagation of the ultrasound beam, which increases with bubble concentration. Pseudoenhancement shows relatively late initiation, progression over time, and nonmarginal location; these findings are different from those seen in typical tumor recurrence, which shows early enhancement and washout at the margin of the ablation zone.

OC12.06 Perinatal outcomes of fetal echogenic lung lesions: an Australian perspective

OC12.06 Perinatal outcomes of fetal echogenic lung lesions: an Australian perspective

Ileocolocolic intussusception secondary to a submucosal lipoma: An unusual cause of intermittent abdominal pain in a 62‐year‐old woman

We present a case of subacute nonobstructing ileocolocolic intussusception secondary to a submucosal lipoma and a mobile cecum diagnosed sonographically in a 62-year-old woman. The patient was seen following a 2-month history of nonspecific intermittent pain in the right and middle abdomen and weight loss. Sonography revealed ongoing intussusception involving distal ascending and transverse colon. Analysis of the distal intussusception end demonstrated a 3.0 x 2.5 cm echogenic polypoid lesion consistent with a lipoma serving as a lead point. The sonographic diagnosis was confirmed at surgery.

Thrombocytopenia as first manifestation of splenic angiosarcoma

Dear Editor, Angiosarcoma is a rare mesenchymal neoplasia with an incidence of only 0.14–0.25 cases per million [1]. Most common sites of occurrence are skin and superficial soft tissues, followed by breast, liver, spleen, and bone. Early stage metastases to lung, liver, and lymph nodes are common and overall prognosis is poor [2, 3]. Only approx. 5% of angiosarcomas originate from the spleen, and the existing casuistic reports suggest a dismal clinical prognosis. Here, we describe a rare case of splenic angiosarcoma leading to thrombocytopenia as first manifestation of the disease. A 64-year-old woman presented as hematologic outpatient inMarch 2008 with isolated thrombocytopenia (58/nl) and chronic, slowly progressive fatigue. Thrombocytopenia was first noted in 2006. Pre-existing medical conditions and physical examination were unremarkable. The remaining full blood count was without pathological findings (hemoglobin 12.2 g/dl, normal erythrocyte indices, leukocytes 6.9/nl with normal differential count). Differential diagnosis for moderate thrombocytopenia included various causes for immune destruction of platelets, impaired thrombocyte production, and hypersplenism. However, laboratory screening tests for lymphoma, autoimmune diseases, and virus infections resulted negative. A bone marrow aspirate gave an unspecific picture with unremarkable cellular properties, normal count of megakaryocytes but diffuse infiltration of mature plasma cells up to 15%. A bone marrow biopsy showed hyperplastic left shifted granulopoiesis, left shifted megakaryopoiesis, and erythropoiesis in a hypercellular tissue, partially accompanied with B-cell-rich non-monoclonal lymphocytic aggregates. An abdominal ultrasound showed massive splenomegaly with multiple highly echogenic circular lesions. Multislice computed tomography (MSCT) confirmed splenomegaly (measuring 21 cm craniocaudal) and revealed multiple hypodense lesions with central hyperdense structures (Fig. 1a). In addition, multiple lytic bone lesions in the vertebral column were present. MSCT-guided biopsy of these lytic bone lesions showed infiltrates of a mesenchymal neoplasia containing atypic mitotic bodies, a proliferation fraction of 40% (MIB-1) and negativity for pancytokeratin and S 100. Immunohistochemistry stained positive for vimentin, CD31, CD34, and factor VIII, but negative for desmin, actin, and HHV8, leading to the diagnosis of angiosarcoma (Fig. 2). Meanwhile, the patient suffered from symptomatic splenomegaly (abdominal pain, symptoms of GI tract displacement), and since splenic angiosarcoma may be complicated by splenic rupture [4, 5], an elective splenectomy was performed. Histological examination confirmed the diagnosis of primary splenic angiosarcoma. In addition, the patient was offered palliative chemotherapy and infusions of bisphosphonates; the latter were started immediately. Chemotherapy with paclitaxel (90 mg/m weekly) began with a delay of several weeks (patient’s choice) at a S. Raffel :B. Hildebrandt : I. Sturm (*) Department of Hematology and Oncology, Charite Campus Virchow Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany e-mail: isrid.sturm@charite.de

Rheological and Physiological Consequences of Conversion of the Maternal Spiral Arteries for Uteroplacental Blood Flow during Human Pregnancy

Physiological conversion of the maternal spiral arteries is key to a successful human pregnancy. It involves loss of smooth muscle and the elastic lamina from the vessel wall as far as the inner third of the myometrium, and is associated with a 5–10-fold dilation at the vessel mouth. Failure of conversion accompanies common complications of pregnancy, such as early-onset preeclampsia and fetal growth restriction. Here, we model the effects of terminal dilation on inflow of blood into the placental intervillous space at term, using dimensions in the literature derived from three-dimensional reconstructions. We observe that dilation slows the rate of flow from 2 to 3m/s in the non-dilated part of an artery of 0.4–0.5mm diameter to approximately 10cm/s at the 2.5mm diameter mouth, depending on the exact radius and viscosity. This rate predicts a transit time through the intervillous space of approximately 25s, which matches observed times closely. The model shows that in the absence of conversion blood will enter the intervillous space as a turbulent jet at rates of 1–2m/s. We speculate that the high momentum will damage villous architecture, rupturing anchoring villi and creating echogenic cystic lesions as evidenced by ultrasound. The retention of smooth muscle will also increase the risk of spontaneous vasoconstriction and ischaemia–reperfusion injury, generating oxidative stress. Dilation has a surprisingly modest impact on total blood flow, and so we suggest the placental pathology associated with deficient conversion is dominated by rheological consequences rather than chronic hypoxia.

Perinatal Imaging in Bronchopulmonary Sequestration

Received September 2, 2008, from the Fetal Medicine Center, Department of Obstetrics and Gynecology, Clinica Las Condes, Santiago, Chile. Revision requested September 8, 2008. Revised manuscript accepted for publication October 7, 2008. I thank Ximena Ortega, MD, for evaluating the prenatal magnetic resonance imaging; Jose M. Cortes, MT, and Juan A. Escaffi, MD, for performing and evaluating the angiographic computed tomography; and Angel Blanco, MD, Jose L. Martinez, MD, and Hernan Villalon, MD, for their substantial contribution to the postnatal care of the infant reported here. This work was supported by the Sociedad Profesional de Medicina Fetal “Fetalmed” Limitada, Chile. Address correspondence to Waldo Sepulveda, MD, Fetal Medicine Center, Clinica Las Condes, Casilla 208, Santiago 20, Chile. E-mail fetalmed@yahoo.com Abbreviations CCAM, cystic congenital adenomatoid malformation; CT, computed tomography; MRI, magnetic resonance imaging 30-year-old woman, gravida 2, para 1, was referred to our center at 21 weeks’ gestation after the prenatal detection of an echogenic mass in the right lung during a second-trimester anatomy scan. Her medical and obstetric histories were unremarkable; the current pregnancy had been otherwise uncomplicated; and the first-trimester scan at 11 weeks confirmed the dates and a normal nuchal translucency thickness measurement. Sonographic examination at referral showed adequate fetal growth and a normal amniotic fluid volume. Detailed examination of the fetal anatomy revealed a predominantly solid echogenic lesion with several small cysts, the largest measuring 3 mm, occupying the lower two-thirds of the right lung (Figure 1, A and B). There were no signs of a mediastinal shift, cardiac compression, abnormal venous return, or additional fetal structural anomalies. Color Doppler sonography depicted a large arterial vessel feeding the mass, which originated from the abdominal aorta (Figure 1C). The diagnosis of pulmonary sequestration was entertained, but the presence of small cysts within the mass also suggested a hybrid lesion associated with cystic congenital adenomatoid malformation (CCAM) of the lung. The pregnancy was followed with serial scans, which showed a slight reduction of the size of the mass, a normal amniotic fluid volume, and no signs of fetal hydrops. Fetal magnetic resonance imaging (MRI), performed at 31 weeks, confirmed the presence of a predominantly solid mass with small cysts in the fetal right lung and a feeding vessel arising from the abdominal aorta and crossing the diaphragm (Figure 2). At 38 weeks, a male neonate was delivered vaginally, weighing 3200 g and with Apgar scores of 9 and 10 at 1 and 5 minutes, respectively. There were no neonatal respiratory complications and the infant remained asymptomatic. Angiographic computed tomography (CT) was per-

Hybrid Epicardial and Endocardial Catheter Ablation in a Patient With Atrial Fibrillation and Suspicious Left Atrial Thrombus

Patients with a left atrial (LA) thrombus are considered at risk of a serious thromboembolic event, and therefore endocardial radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) is contraindicated. However, RFCA of AF is inevitable in some patients with highly symptomatic AF and suspicious LA masses resembling thrombus. A patient was treated who underwent hybrid epi- and endocardial RFCA for drug resistant, highly symptomatic, paroxysmal AF with a suspicious left atrial (LA) thrombus that was a lamellated, thickened, echogenic lesion attached to the LA anterior wall and resistant to anticoagulation. During RFCA, contact with the LA endocardium was minimized using hybrid epi- and endocardial ablation guided by computed tomography merged with 3-dimensional electroanatomical mapping (NavX). The patient has been free of AF without antiarrhythmic drugs for 6 months, therefore hybrid epi- and endocardial ablation may be an effective therapy for AF patients with a LA mass.

Intravascular ultrasound assessment of coronary artery involvement in Fabry disease

We used intravascular ultrasound (IVUS) to characterize coronary artery involvement in patients with Fabry disease (FD). Nine FD patients (5 women) were matched to 10 control patients (5 women) chosen from our IVUS database. Standard volumetric IVUS analyses were performed along with assessment of plaque echodensity. Plaques in FD patients were diffuse and hypoechogenic compared with more focal and more echogenic lesions in control patients. Echogenicity of plaques was significantly lower in FD patients (median 30.7 +/- 12.9 vs 55.9 +/- 15.7, p = 0.0052, mean 37.2 +/- 15.6 vs 66.2 +/- 13.3, p = 0.0014). Diffusiveness was assessed as differences between mean and median plaque burden versus the plaque burden in each of the analysed cross-sections. These differences were lower in FD vs controls (5.8 +/- 4.8 vs 8.7 +/- 6.6, p < 0.001 for mean, and 5.8 +/- 4.9 vs 8.8 +/- 7.3, p < 0.001 for median) indicating a more diffuse involvement. The occurrence of lipid cores was significantly higher in FD patients than in controls (2.4 +/- 1.5 vs 1.0 +/- 0.94, p = 0.02). IVUS showed diffuse hypoechogenic plaques in patients with FD. The explanation may be higher lipid content in plaques and accumulation of glycosphingolipid in smooth-muscle and endothelial cells.

Prenatal diagnosis and outcome of echogenic fetal lung lesions

To describe the antenatal findings and outcome of fetuses with echogenic lung lesions. This was a retrospective study of the prenatal sonographic features, antenatal management and outcome of 193 fetuses with an echogenic lung lesion diagnosed at 18-35 weeks of gestation. There were nine cases of congenital high airway obstruction syndrome (CHAOS), 170 cases of cystic adenomatoid malformation (CAM) and 14 cases of pulmonary sequestration (PS). A literature search was also carried out to compare our data with those of previous series. The prognosis in our series of fetuses with CHAOS was invariably poor, but the literature describes a handful of survivors after delivery by Cesarean section and ex-utero intrapartum therapy (EXIT). Of the cases in our series with PS and no pleural effusions, more than 95% survived; in half of these cases the lesion resolved antenatally and in the other half sequestrectomy was carried out postnatally. In cases with PS and pleural effusions, successful treatment was provided by the placement of thoracoamniotic shunts or occlusion of the feeding blood vessel by ultrasound-guided laser coagulation or injection of sclerosants. In cases with CAM and no hydrops, there was more than 95% survival and in up to half of the cases there was sonographic evidence of spontaneous antenatal resolution of the hyperechogenic lesion, which was confirmed by postnatal imaging in about 60% of the cases. Of the cases with CAM with hydrops managed expectantly, more than 95% died before or after birth. Of the cases with macrocystic CAM with hydrops, two-thirds survived after placement of a thoracoamniotic shunt. In cases with microcystic CAM with hydrops, there is some evidence that open fetal surgery with lobectomy could improve survival but such treatment is highly invasive for the mother. CHAOS is a severe abnormality, whereas CAM and PS are associated with a good prognosis. In a high proportion of fetuses with hyperechogenic lung lesion, there is spontaneous antenatal resolution and the underlying pathology may be transient bronchial obstruction.

Sonography under Daylight Conditions.

Gray scale image assessment in clinical ultrasound requires working in dim light or a dark room. Daylight conditions offer the advantage of shorter visual reaction time and enhanced visual perception. Look-up table manipulations could improve image brightness. We investigated the possibility of brightness and contrast enhancement of coloured adaptive linear look-up tables (CALUT's) and their artifact resistance. Therefore under real-time conditions red/brown, green and blue CALUT's were calculated using the gray scale distribution (mean and standard deviation) of the actual image. The changes in contrast of several structural features (echo-poor and echogenic lesions, artifacts) were assessed by clinical investigators (n = 7). The CALUT's produced, independent of the original, images with constant brightness and contrast. Even under daylight conditions no artifacts appeared. Under scotopic conditions the red/brown CALUT's showed the best results compared to the unchanged image and the gray, green, and blue CALUT's. Hyper and hypoechoic differences with small contrast to the surrounding tissue are enhanced and can be detected more easily. Daylight sonography allows examination even in non-darkened rooms without loss of information. Eye adaptation to changing light conditions is no longer necessary; the offered image information is more suitable for the eye.

Echoreiche Milzprozesse - Häufigkeit und Differentialdiagnose

In order to estimate the incidence and clinical relevance of echogenic focal lesions in the spleen, 121,372 ultrasound investigations from seven laboratories were evaluated. Ninety-two cases with echogenic lesions in the spleen were reviewed (incidence: 3.2 to 14.2 of 10,000 patients). Differential diagnosis included neoplastic tumors (17.4%; five metastases, three lymphomas, seven hemangiomas, one lymphangiomatosis), vascular disorders (17.4%: bleeding, infarct) and inflammatory focal lesions (8.7%; abscess, calcifications). Follow-up studies showed no change in size and pattern in a further 17.4% of the lesions, indicating benign disorders. Thirty patients suffered from a malignant condition with splenic metastasis or lymphomas in eight cases. In a further five patients, it was possible to confirm echogenic hemangiomas. There are no specific echographic patterns which differentiate hemangiomas from malignant tumors.

Vaskuläre Raumforderungen der Arteria carotis - Nachweis mit der farbkodierten Dopplersonographie

Nine patients with a cervical tumour, diagnosed by duplex Doppler sonography were additionally evaluated by colour-coded Doppler sonography (CCDS). The duplex Doppler diagnosis of three internal carotid artery aneurysm was confirmed by CCDS in only one patient. In the remaining two cases CCDS identified a marked coiling of the internal carotid artery. Three low echogenic lesions, interpreted as cervical lymphomas by conventional Doppler sonography were identified as two internal carotid aneurysm with partial thrombosis and a carotid body tumour in the third patient by CCDS. Duplex-Doppler sonography and CCDS agreed in the diagnosis of two AV-malformations and one carotid body tumour. Angiography confirmed the CCDS-diagnosis in 7 patients. In the two patients with coiling of the ICA angiographic evaluation was not performed. Thus, CCDS was superior to duplex Doppler sonography in the evaluation of vascular lesions of the extracranial section of the carotid artery and provided additional diagnostic information.

Ultraschallgeführte Feinnadelbiopsie herdförmiger Lebererkrankungen - Teil II: Benigne herdförmige Lebererkrankungen

Sixty patients with benign focal liver disease underwent sonography-guided percutaneous fine needle biopsy for definitive diagnosis. The benignancy of all lesions was determined accurately by cytohistologic evaluation. All 44 liquid space-occupying lesions (30 hepatic cysts, 9 abscesses, 3 hematomas, 2 serous residual cavities after surgery) could be classified by cytological, biochemical and bacterial examination. The diagnosis of hepatic hemangiomas by fine needle puncture is problematic, because the cytological identification of benign endothelial cells is difficult. The histological examination of tissue cylinders of 4 small echogenic lesions revealed focal fatty change of the liver. Tissue fragments of focal nodular hyperplasias and liver cell adenomas showed histologically typical liver cells arranged in trabecular structure. The additional identification of bile ducts supplies proof of focal nodular hyperplasia and excludes liver cell adenoma. Percutaneous puncture of liver abscesses and cysts afforded effective therapeutic decompression. Eight out of 9 liver abscesses were cured by evacuating fine needle puncture. More than 50% of the liver cysts showed long-term growth shrinkage subsequent to puncture. The histological confirmation of benign and malignant liver tumors by sonographyguided fine needle biopsy is considered a decisive step forward in the diagnostic possibilities of update imaging methods.

OP02.04: Prenatal intervention in fetuses with severe congenital diaphragmatic hernia and congenital cystic adenomatoid malformation

Objectives: The natural history of echogenic lung lesions such as congenital cystic adenomatoid malformation (CCAM) and pulmonary sequestration (PS) has been altered by the advent of antenatal ultrasonography. Initial reports were characterized by a high incidence of adverse features (hydrops) and a poor outcome and did not accord with recent experience. Our purpose was to review the evolution and outcome of these lesions in our series. Methods: A retrospective review was conducted on fetuses diagnosed antenatally in the Fetal Medicine Unit of Hospital Vall d Hebron in Barcelona, Spain, between 2001 and 2007. A computer search identified all referred cases, and the records of these patients were examined to determine the pregnancy outcome. Results: In a 6-year period, 34 fetuses with echogenic lung lesions were referred for further management. The median age at diagnosis was 23 (range, 20–41) weeks. The lesion was on the right side in 19 (55%) and 15 (45%). All cases were unilateral. One case was diagnosed as CCAM type I (3%), 14 CCAM type II (41%) 11 CCAM type III (32%), 3 PS (8.8%) and five were mixed PS/CCAM (15%). All the fetuses had no associated anomalies and normal karyotype except one (47 XX+18). Termination of pregnancy was performed in seven cases of CCAM. In all cases histologic examination showed definitive diagnostic features of CCAM. In two cases diagnostic type of CCAM was changed from CCAM type II to type I and from CCAM type III to type II. Mediastinal shift was present in 16 fetuses (47%). Severe signs of fetal distress (hydrops) were present in three (8.8%). Because of hydrops, antenatal intervention was performed in two fetuses (thoracoamniotic shunting) and it was resolved. During the course of the pregnancy 70.5% (24/34) cases reduced in size or resolved spontaneously. All cases had good perinatal outcome. Conclusions: Most cases of prenatally diagnosed echogenic lung lesions had a good outcome. This review has positively influenced the counseling of women with this diagnosis.