Echogenic Rim Research Articles

Pseudoangiomatous Stromal Hyperplasia: Radiologic-Pathologic Correlation.

Pseudoangiomatous stromal hyperplasia (PASH) is a benign mesenchymal proliferative lesion of the breast. PASH is postulated to be hormonally induced and predominantly occurs in premenopausal women and postmenopausal women on menopausal hormone therapy. Clinical presentation varies from screen-detected lesions to palpable masses. Imaging findings of PASH are nonspecific. The most common mammographic findings are an oval or round circumscribed non-calcified mass or developing asymmetry. On US, PASH is often seen as an oval hypoechoic mass that may be circumscribed and can have an echogenic rim, or, when manifest as mammographic asymmetry, US may show a corresponding non-mass focal area of echogenic tissue. Limited studies have investigated the MRI appearance, with PASH most often manifesting as non-mass enhancement, or, less often, as an oval or irregular mass with persistent kinetics. Histopathologically, PASH can be mistaken for a fibroadenoma or phyllodes tumor and has features overlapping low-grade angiosarcoma. Assessment of radiologic-pathologic concordance is particularly important as PASH is often an incidental finding, adjacent to the targeted lesion at histopathology. Surgical excision or repeat core-needle biopsy is necessary for discordant suspicious cases. After a benign, concordant diagnosis of PASH, the patient may resume routine screening.

An ultrasonographic study to evaluate the correlation of calcified yolk sac with spontaneous abortion

Background: The yolk sac is a small, membranous structure, which is situated outside the embryo and has a variety of functions during embryonic development. The yolk sac plays an important role in critical biological functions during early gestation, which includes primitive hematopoiesis as well as production of germ cells. It can be visualized between 6 and 12 weeks of pregnancy by ultrasonography as a regularly rounded extra-amniotic structure when the gestational sac reaches dimensions of 8–10 mm. On sonography, the yolk sac appears as a round structure which has an anechoic center bordered by a regular well-defined echogenic rim. Thus, a normal yolk sac is a yolk sac with echogenic rim and hypoechoic center, whereas yolk sac with hypoechoic rim or hyperechoic center is considered as calcified yolk sac. Aim and Objectives: To study the correlation of calcified yolk sac with spontaneous abortion in the first trimester of pregnancy. Materials and Methods: We studied 144 pregnant females who were in their first trimester of pregnancy, referred by the department of obstetrics and gynecology. The echotexture of yolk sac was observed by transvaginal sonography and its correlation with spontaneous abortion. Results: Yolk sac was present in 140 cases (97.22%), and in 4 cases (2.78%), it was absent. Out of 140 cases, it was calcified in two cases and normal in 138. All the cases in which there was absence of yolk sac or calcified yolk sac resulted into spontaneous abortion. Conclusion: Accurate recognition of the normal and abnormal sonographic findings related to yolk sac can be used to anticipate the course of pregnancy which may be used as good tool in clinical practice to predict whether a pregnancy is going to have a good or a poor outcome.

English

Thyroid pathology is very common in general population, even when on inspection no abnormality is detected, nodules are seen on ultrasound sonography (USG). We are describing importance of peripheral halo sign in the diagnosis of benign nodules. Among all the endocrine gland lesions noted in India, thyroid lesion is the most common. In about 19 - 60 % of the adult population thyroid nodules are seen; however, less than 1 % of the thyroid nodules are malignant. Halo seen on ultrasound near the thyroid is considered as reliable and specific sign of benignity. 1 The morphological characteristics that suggest that the thyroid nodule is benign are echogenicity of thyroid gland in that being the identical echo signal or being moderately hyperechogenic corresponding to surrounding normal thyroid tissue. The solid nodule may be accompanied by a hypoechoic halo, which represents compressed thyroid tissue, fibrous connective tissue and vessels. The cystic nodule lesion contains colloid, and this appears as a hyper-echogenic spot with “comet-tail shadowing or ring-down sign”.2 The spongiform appearance on ultrasound has specificity of 99.7 % for benign disease it has 98.5 % negative predictive value for malignancy. 3,4 At the peripheries of the nodule, complete eggshell calcification is noted.5 A thyroid nodule with the above-mentioned characteristics is considered to be benign nodule and it does not require fine-needle aspiration cytology (FNAC) and in such patients there is neither a risk of malignancy nor a follow up USG is recommended.2 In benign thyroid lesion, there is rapid and controlled growth of thyroid cells compressing the surrounding thyroid parenchyma appearing as the echogenic rim called as sonolucent halo, on the contrary, malignant lesion has spontaneous but uncontrolled growth of the cells which lack cellular cohesion causing incomplete halo.6

Ultrasound-Based Nomogram for Distinguishing Malignant Tumors from Nodular Sclerosing Adenoses in Solid Breast Lesions.

Nodular sclerosing adenoses (NSAs) and malignant tumors (MTs) may coexist and are often classified into the same Breast Imaging Reporting and Data System (BI-RADS) category. We aimed to build and validate an ultrasound-based nomogram to distinguish MT from NSA for building a precise sequence of biopsies. The training cohort included 156 patients (156 masses) with NSA or MT at one study institution. We used best subset regression to determine the predictors for building a nomogram from ultrasonic characteristics and patients' age. Model performance and clinical utility were evaluated using Brier score, concordance (C)-index, calibration curve, and decision curve analysis. The independent validation cohort consisted of 162 patients (162 masses) from a separate institution. Through best subset regression, we selected 6 predictors to develop nomogram: age, calcification, echogenic rim, vascularity distribution, tumor size, and thickness of breast parenchyma. Brier score and C-index of the nomogram in the training cohort were 0.068 and 0.967 (95% confidence interval [CI]: 0.941-0.993), respectively. In addition, calibration curve demonstrated good agreement between prediction and pathological result. In the validation cohort, the nomogram still obtained a favorable C-index score of 0.951 (95% CI: 0.919-0.983) and fine calibration. Decision curve analysis showed that the model was clinically useful. If multiple NSA and MT masses are present in the same patient and are classified into the same BI-RADS category, our nomogram can be used as a supplement to the BI-RADS category for accurate biopsy of the mass most likely to be MT.

Intracranial Hemorrhage

Intracranial Hemorrhage

"Pseudogestational Sac" and Other 1980s-Era Concepts in Early First-Trimester Ultrasound: Are They Still Relevant Today?

To determine whether an intrauterine round or oval fluid collection ("saclike structure") can prove to be either an intrauterine pregnancy or intrauterine fluid in conjunction with an ectopic pregnancy (sometimes termed "pseudogestational sac") and whether ultrasound features, including the presence or absence of an echogenic rim, "double sac sign" (DSS), or "intradecidual sign" (IDS), are helpful for establishing the diagnosis or predicting the prognosis. We identified all sonograms obtained from women with positive serum human chorionic gonadotropin results at our institution between January 1, 2012, and June 30, 2018, meeting the following criteria: presence of an intrauterine saclike structure without a yolk sac or embryo; no extraovarian adnexal mass; and follow-up information identifying the location of the pregnancy as intrauterine or ectopic. Study authors reviewed sonograms in all cases and recorded the following information: presence or absence of each of an echogenic rim around the collection, a DSS, and an IDS, as well as the mean sac diameter. The indications for the initial ultrasound examinations were recorded. A total of 649 sonograms met the inclusion criteria. Of these, 598 fluid collections showed an echogenic rim, 182 a DSS, and 347 an IDS (findings not mutually exclusive). In all 649 cases, a subsequent sonogram or other clinical follow-up confirmed that the patient had an intrauterine pregnancy. That is, none of the fluid collections proved to be a pseudogestational sac. In total, 41.2% were live at the end of the first trimester, and 58.8% miscarried. The prognosis was better in cases with, compared to without, an IDS (P = .01, χ2 ), but no ultrasound feature was clinically useful for ruling in or excluding a good prognosis. In a woman with positive human chorionic gonadotropin results and no extraovarian adnexal mass, the ultrasound finding of an intrauterine saclike structure is virtually certain to be a gestational sac. Ultrasound features of the structure are of no diagnostic or clinically useful prognostic value. Concepts introduced 30 to 40 years ago when ultrasound equipment had far lower resolution than currently, including a DDS, an IDS, and a pseudogestational sac, have no role today in assessing early pregnancy.

Can acoustic structural quantification be used to characterize the ultrasound echotexture of the peripheral zone of breast lesions?

BACKGROUND:Besides mammography, breast ultrasound is the most important imaging modality for women with suspected breast cancer. New software tools bear high potential for improved detectability and specification of malignant breast lesions.OBJECTIVE:To compare the halo depicted around malignant breast lesions by ultrasound using Acoustic Structure Quantification (ASQ) of raw image data with the echogenic rim seen in B-mode ultrasound.METHODS:This retrospective study included 37 women for whom conventional B-mode ultrasound of the breast and ASQ were available as well as histopathology findings for comparison. Software tools were used to measure the halo area or echogenic rim and tumor area and calculate halo-to-lesion ratios for the two ultrasound modes. Six inexperienced readers characterized the breast lesions based on this information. Specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) were determined. ANOVA, the Wilcoxon test, and ROC curve analysis were performed.RESULTS:There was a linear relationship between ASQ-based and B-mode-based halo-to-lesion ratios; however, a systematic error was also noted. ASQ-derived ratios tended to be higher for breast lesions with lymphangioinvasion (p = 0.051, n.s.) and higher N-stages (p > 0.925, n.s.), while there was no correlation with other markers. Because of the significantly greater conspicuity of peritumoral halos in the ASQ mode, inexperienced readers achieved greater sensitivity (78% vs. 74%) and specificity (75% vs. 71%) and higher NPVs (75% vs. 71%) and PPVs (78% vs. 74%) compared with B-mode images. Greater halo conspicuity affected the identification of malignant lesions with both modes; ASQ was found to be particularly well suited (FBimage (1,100) = 19.253, p < 0.001; FASQ (1,100) = 52.338, p < 0.001). The inexperienced readers were significantly more confident about their diagnosis using the ASQ maps (z = –3.023, p = 0.003).CONCLUSIONS:We conclude that the halo in ASQ and the echogenic rim in B-mode ultrasound are attributable to different morphologic correlates. ASQ improves diagnostic accuracy and confidence of inexperienced examiners because of improved halo visibility.

Identification of a correlation between the sonographic appearance and molecular subtype of invasive breast cancer: A review of 311 cases

PurposeTo identify the ultrasound and clinical features related to the different molecular subtypes of invasive breast cancer. MethodsSonographic and clinical data of 311 surgically confirmed breast cancer cases were retrospectively reviewed and compared based on various subtypes. ResultsLuminal A (LA) breast cancers were associated with a low histologic grade, spiculated margins, an echogenic rim and posterior acoustic attenuation. The human epidermal growth factor receptor 2-positive (HER2+) subtype was characterized by a high grade, indistinct and spiculated margins, enhanced posterior acoustics, calcifications, and vascularity. Triple negative breast cancers (TNBCs) were more likely to present with a high tumor grade, circumscribed and microlobulated margins, and the absence of an echogenic rim and calcifications; to be markedly hypoechoic; and to have posterior acoustic enhancement and hypovascularity. Luminal B (LB) cancers were more likely to be associated with an indistinct margin and relative vascularity. ConclusionOur study demonstrated that the sonographic and clinical features of breast cancer were significantly correlated with the molecular subtype. The imaging findings of the different subtypes and their biological implications may provide additional auxiliary information for clinical diagnosis, systemic treatment and prognosis prediction.

AIUM-ACR-ACOG-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetric Ultrasound Examinations.

AIUM-ACR-ACOG-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetric Ultrasound Examinations.

Can Cut-Off-Values for Tumor Size or Patient Age in Breast Ultrasound Reduce Unnecessary Biopsies or is it all About Bi-rads?- A Retrospective Analysis of 763 Biopsied T1-Sized Lesions.

To assess whether it is possible to establish a size cut-off-value for sonographically visible breast lesions in a screening situation, under which it is justifiable to obviate a biopsy and to evaluate the grayscale characteristics of the identified lesions. Images of sonographically visible and biopsied breast lesions of 684 patients were retrospectively reviewed and assessed for the following parameters: size, shape, margin, lesion boundary, vascularity, patient's age, side of breast, histological result, and initial BI-RADS category. Statistical analyses (t-test for independent variables, ROC analyses, binary logistic regression models, cross-tabulations, positive/negative predictive values) were performed using IBM SPSS (Version 21.0). Of all 763 biopsied lesions, 223 (29.2%) showed a malignant histologic result, while 540 (70.8%) were benign. Although we did find a statistically significant correlation of malignancy and lesion size (p=0.031), it was not possible to define a cut-off value, under which it would be justifiable to obviate a biopsy in terms of sensitivity and specificity (AUC: 0.558) at any age. Lesions showing the characteristics of a round or oval shape, a sharp delineation and no echogenic rim (n=112) were benign with an NPV of 99.1%. It is not possible to define a cut-off value for size or age, under which a biopsy of a sonographically visible breast lesion can be obviated in the screening situation. The combination of the 3 grayscale characteristics, shape (round or oval), margin (circumscribed) and no echogenic-rim sign, showed an NPV of 99.1%. Therefore, it seems appropriate to classify such lesions as BI-RADS 2.

Changes in echogenicity of hepatic hemangiomas during the valsalva maneuver.

We aimed to evaluate changes in echogenicity of hepatic hemangiomas during the Valsalva maneuver. We examined 16 liver hemangiomas in 12 patients with a mean diameter of 1.5 cm (range, 0.7-2.2 cm), which showed variations in echogenicity during the Valsalva maneuver. Two radiologists reviewed the sonographic (US) images of the hemangiomas at three different times: prior to the Valsalva maneuver, during the Valsalva maneuver, and on follow-up US examinations. Prior to Valsalva maneuver, the 16 hemangiomas appeared as hypoechoic nodules with an echogenic rim (n = 7), homogeneously echogenic nodules (n = 5), one hypoechoic nodule with sound-through enhancement, one heterogeneous nodule with a hyperechoic rim, one heterogeneous nodule, and one echogenic nodule with a hyperechoic rim. During the Valsalva maneuver, increased echogenicity was observed in 11 cases, as a diffuse increase in 5 cases, and as a partial increase in 6. Prior to the Valsalva maneuver, 9 of 16 hemangiomas exhibited an echogenic rim. During the maneuver, all the rims were accentuated, and an additional five hemangiomas exhibited an echogenic rim. Throughout follow-up, 12 of 15 hemangiomas underwent some echogenicity change. Use of the Valsalva maneuver during US examination of the liver can increase the echogenicity of hepatic hemangiomas and accentuate the echogenic rim, which could enhance the operator's confidence in the diagnosis of hemangioma. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:328-331, 2017.

Nodular Fasciitis: Sonographic–Pathologic Correlation

We evaluated nodular fasciitis (NF) in 19 patients, focusing on the correlation between its sonographic and histopathologic features. Sonograms were retrospectively reviewed, and the location, shape, margin, echogenicity, echogenic rim, peripheral hyper-echoic nodules, posterior enhancement and vascularity of the lesions were recorded. In the histopathologic analysis, three patterns—infiltrating, pushing border and well circumscribed—were identified, and culture-like tissue centers were classified according to the distribution of focal keloid-like collagen bundles: uneven or even. For the sonographic–pathologic correlation, most NF cases were inhomogeneously hypo-echoic and had an echogenic rim, with an infiltrating or pushing border pattern. In addition, all NF cases with the infiltrating pattern were observed to have peripheral hyper-echoic nodules in sonograms. Thus, echogenic rims may be associated with the peripheral adipose tissues in infiltrating pattern, and the degree of infiltration may be associated with specific sonographic features of NF.

Diagnosis and Management of Ectopic Pregnancy: Green-top Guideline No. 21.

Diagnosis and Management of Ectopic Pregnancy: Green-top Guideline No. 21.

Hyper-Echoic Rim in Thyroid Nodules: A New Ultrasonographic Feature for Malignancy Prediction

The goal of this study was to verify the ultrasound features of hyper-echoic rims in thyroid nodules and to evaluate their diagnostic value in predicting thyroid malignancies. We retrospectively analyzed 228 pathologically proven thyroid nodules (137 malignant and 91 benign nodules). Forty-eight thyroid nodules had a hyper echogenic rim. All malignant nodules (137) were papillary carcinomas, which were studied to identify the correlation between the hyper-echoic rim (detected by ultrasound) and other histologic features. Presence of a hyper-echoic rim had high specificity (94.51%), but low sensitivity (31.39%) in predicting malignancy (p < 0.05). Thirty-seven of 43 malignant nodules had boundary zones of mixed structure (apparent fibrous stroma bands or dense collagenous border with a mixed population of cancerous cells) under microscopic examination. In conclusion, the hyper-echogenic rim could be one additional ultrasound parameter in the diagnosis of thyroid lesions.

Ectopic Pregnancy in the Era of Medical Abortion: Are We Ready for It? Spectrum of Sonographic Findings and Our Experience in a Tertiary Care Service Hospital of India

The aim of this study was to share our experience of clinical presentation and ultrasonographic findings in cases of ectopic pregnancy especially in the context of usage of unsupervised medical abortifacients. This is prospective study conducted over a period of 1year extending from August 01, 2009 to July 31, 2010 in a tertiary care Armed Forces Hospital of India. Clinically and or sonologically suspected cases of ectopic pregnancy formed the study group. Detailed clinical, menstrual, and treatment history was obtained for each patient. Ultrasonography (USG) was done with multifrequency convex (2.5-6MHz) followed by transvaginal (6-10MHz) probes. Operative findings were noted and recorded in each case. In the study period, a total of 1958 pregnant patients were admitted and treated, which included 1690 deliveries and 268 abortions. Based on USG findings, 16 cases (0.8%) of ectopic pregnancy were diagnosed. While four patients were treated medically (with methotrexate), 12 cases underwent surgery. Out of 16 cases, 10 cases were suspected clinically as ectopic pregnancy. Features suggestive of menorrhagia, threatened abortion, and pelvic inflammatory disease were present in five, three, and three cases, respectively. History of intake of medical abortifacients (MA) (mifepristone followed by misoprostol) was present in 07 (43.75%) cases. On USG, commonest abnormality was a complex adnexal mass seen in 12 (75%) cases. Gestational sac with definite embryo within and surrounding echogenic rim was seen in five cases. Live ectopic pregnancy was diagnosed in two (12.5%) cases. Endometrial thickness was less than 10mm in all cases who had taken MA. Pseudo gestation sac was seen in 02 (12.5%) cases. Significant hemoperitoneum was present in 10 out of 12 cases operated. Organized hematoma in pelvis masking the presence of adnexal mass was noted in three cases. Over-the-counter availability, failure to strictly follow the guidelines, unsupervised usage of MA along with atypical clinical history have increased diagnostic dilemma in ectopic pregnancy. Sonographic findings are frequently atypical in such cases. Ectopic pregnancy may remain under-diagnosed with potentially serious consequences in patients who have taken MA without prior confirmation of intrauterine gestation.

Sonobreast: Predicting Individualized Probabilities of Malignancy in Solid Breast Masses with Echographic Expression

To create an individualized predictive tool for the risk of malignancy in solid breast masses, based on echographic and clinical characteristics. Research Ethics Committee approval and informed consent were obtained. This multi-center study included 1,403 solid breast masses prospectively. Each ultrasound feature was analyzed and compared with the definitive diagnosis. The ultrasound results, women's ages and family histories of breast cancer were included in a multivariate logistic regression model. Among the 1,403 lesions included in the study, 1,390 (99.1%) had a conclusive diagnosis: 343 malignant tumors (24.7%), and 1,047 benign masses (75.3%). The odds ratio (and confidence interval) for breast malignancy for each variable included in the model, as calculated by multivariate analysis, were as follows: irregular shape/noncircumscribed margins, 16.02 (7.75-33.09); heterogeneous echo texture, 4.50 (2.42-8.23); vertical orientation (not parallel to the skin), 2.23 (1.04-4.75); anterior echogenic rim, 2.62 (1.09-6.31); posterior shadowing, 2.38 (1.23-4.62); age more than 40 years, 2.19 (1.26-3.81); positive first-degree family history (mother, sister or daughter), 7.50 (2.65-21.18). There was no advantage in including the presence of internal vascularity, presence of thickened Cooper's ligaments or size of the mass, in the model. The predictive tool was named SONOBREAST and it is freely available for medical purposes on the internet site: http://www.sonobreast.com. The probability of malignancy in breast masses can be specified based on their ultrasound features, the woman's age and the family history of breast cancer.

Subcutaneous epidermal inclusion cysts: Ultrasound (US) and MR imaging findings

To describe the characteristic US and MR findings of subcutaneous epidermal inclusion cysts. Seventy-nine patients with subcutaneous epidermal inclusion cysts underwent US (n = 70), MR (n = 7), or both (n = 2). On US, the margin, shape, echogenicity, through-transmission, wall, internal debris and vascularity were evaluated. On MR, the shape, wall, signal intensity, internal debris, and enhancement pattern were evaluated. On US, characteristic findings were well circumscribed (n = 69, 96%), ovoid-shaped (n = 56, 78%), heterogeneously and mildly echogenic (n = 66, 92%), increased through-transmission (n = 66, 92%) and low echoic rim (n = 48, 67%). Internal debris was seen in 31 cases (43%) and often contained linear echogenic reflections (n = 12, 17%), dark clefts (n = 13, 18%), or a mixture (n = 5, 7%). Most masses showed no Doppler flow (n = 70, 97%). On MR, all cases demonstrated a well-demarcated oval-shaped mass with a surrounding rim. On T1-weighted image (WI), the mass showed slightly high T1 signal in 4/9 (44%) and iso-signal in 5/9 (56%). On T2WI, the mass showed high signal in 6/9 (67%), intermediate in 2/9 (22%), and a target appearance in 1/9 (11%). Internal linear dark T2 signal debris was observed in 4/9 (44%). All lesions showed peripheral rim enhancement without central enhancement. On US, subcutaneous epidermal inclusion cysts are usually well-circumscribed, oval-shaped, mildly echogenic masses with occasional linear anechoic and/or echogenic reflections, increased through-transmission, hypoechoic rim and no Doppler flow. On MR, an intermediate to high T2 signal mass with occasional low signal debris and no central enhancement can strengthen the diagnosis.

Unusual sonographic appearance of a huge angiomyolipoma of the liver

Hepatic angiomyolipoma is a rare, benign, hepatic mesenchymal neoplasm. We report a case of an extremely large hepatic angiomyolipoma in a 58-year-old woman with unusual sonographic features. The tumor was well demarcated from the surrounding liver and showed a heterogeneous cystic appearance with a thick echogenic rim. Color Doppler showed blood flow in the echogenic rim and around the lesion. Contrast sonography demonstrated strong enhancement in the solid rim from early arterial phase to the late phase and no enhancement in the central cystic part of the lesion. Spiral CT showed a well-defined huge heterogeneous cystic mass with fatty density. At surgery the tumor was soft and encapsulated with a thin, smooth membrane. The cut surface of the tumor revealed a cystic appearance with necrotic tissue. The diagnosis of hepatic angiomyolipoma was confirmed by immunohistochemistry.

Detection of enlarged yolk sac on early ultrasound is associated with adverse pregnancy outcomes

Pregnancies with mean yolk sac diameter>or=5 mm on early ultrasound require monitoring and counseling about a threefold increased risk for first-trimester loss independent of maternal risk factors such as age, body mass index, polycystic ovary syndrome, smoking, and diabetes. In addition, our study shows for the first time that enlarged yolk sac diameter may be associated with an increased risk of preterm delivery.

Inflammatory pseudotumor (myoblastic tumor) of the breast: A case report and review of the literature

Inflammatory pseudotumor of the breast is a very rare cause of breast mass. To our knowledge, only a few cases have been described in the English literature. In this case, the lesion appeared on mammography as a round high-density mass with ill-defined margins and on sonography as an irregular mass of complex echogenicity with ill-defined margins and an echogenic rim. The lesion was resected with no evidence of local recurrence after 3 years.