Homogeneous Echotexture Research Articles

Screening for Early Pancreatic Neoplasia in High-Risk Individuals: A Prospective Controlled Study

Individuals with a strong family history of pancreatic cancer and persons with Peutz-Jeghers syndrome (PJS) have an increased risk for pancreatic cancer. This study screened for early pancreatic neoplasia and compared the pancreatic abnormalities in high-risk individuals and control subjects. High-risk individuals with PJS or a strong family history of pancreatic cancer were prospectively evaluated with baseline and 12-month computed tomography (CT) scan and endoscopic ultrasonography (EUS). If EUS was abnormal, EUS-fine-needle aspiration and endoscopic retrograde cholangiopancreatography (ERCP) were performed. Surgery was offered to patients with potentially neoplastic lesions. Radiologic findings and pathologic diagnoses were compared. Patients undergoing EUS and/or ERCP for benign non-pancreatic indications were concurrently enrolled as control subjects. Seventy-eight high-risk patients (72 from familial pancreatic cancer kindreds, 6 PJS) and 149 control patients were studied. To date, 8 patients with pancreatic neoplasia have been confirmed by surgery or fine-needle aspiration (10% yield of screening); 6 patients had 8 benign intraductal papillary mucinous neoplasms (IPMNs), 1 had an IPMN that progressed to invasive ductal adenocarcinoma, and 1 had pancreatic intraepithelial neoplasia. EUS and CT also diagnosed 3 patients with 5 extrapancreatic neoplasms. At EUS and ERCP abnormalities suggestive of chronic pancreatitis were more common in high-risk patients than in control subjects. Screening EUS and CT diagnosed significant asymptomatic pancreatic and extrapancreatic neoplasms in high-risk individuals. IPMN should be considered a part of the phenotype of familial pancreatic cancer. Abnormalities suggestive of chronic pancreatitis are identified more commonly at EUS and ERCP in high-risk individuals.

Novel use of ultrasound-guided surface marking of head and neck tumors invading facial skin

Malignant tumors of deep head and neck structures can invade skin, but the tumor periphery is difficult to assess clinically. The surgeon's dilemma is achieving tumor clearance with safe margins while at the same time minimizing skin loss on the face. We show, in 2 cases involving the face, that high-resolution diagnostic ultrasound was superior to CT scan in demonstrating the periphery of the tumor. The tumor was distinguished from surrounding edema by its lower echogenicity and homogeneous echotexture. The maximum contour of the tumor was marked on the skin surface with ink under ultrasound guidance. The ink marking aided excision and reconstruction planning. Subsequent histology showed the surgical margins were clear of tumor. The patients remained tumor-free for more than 3 years. Ultrasound imaging therefore shows good potential for planning surgical resection with a safe margin and for aiding decisions on donor site and type of flap for reconstruction.

Adenomyoepithelioma of the Breast

Adenomyoepithelioma of the breast is a rare lesion characterized by biphasic proliferation of ductal epithelium and myoepithelial cells. A 37-year-old female presented with a non-tender, mobile, smooth mass located in the retroareolar area of her left breast. Ultrasonography revealed a 1.76 × 1.73 × 1.23 cm wider-than-tall tumor with homogeneous hypoechoic echotexture. The tumor margins were smooth with a thin echogenic capsule. The tumor was compressible and had posterior acoustic enhancement. Histo-pathologic analysis demonstrated a well-circumscribed tumor with mammary ductal epithelium and myoepithelium in the fibrous stroma. Immunohistochemical staining was positive for smooth muscle actin, vimentin, and S-100 protein in the myoepithelial cells. No recurrence or distant metastases was observed during a 14-month follow-up period.

Chronic recurring infarction of the spleen: sonographic patterns and complications.

Splenic infarction is a major problem of splenic pathology but is characterized by a high tendency for complete healing. The purpose of this study is to describe frequency, sonographic patterns, and complications of chronic infarction (CI) METHODS: Between 1980-2001 550 patients with focal splenic lesions were diagnosed by ultrasound. Eighty patients had an acute infarction, and in 14 cases a chronic infarction was diagnosed and confirmed by cytohistology/splenectomy (n = 3) or sonographic follow-up examination (n = 11). All patients with Cl had been investigated by B-mode sonography and colour Doppler sonography (CDS). Data were retrospectively evaluated. Two types of Cl could be discriminated. Type I morphology (n =8) was predominantly found in homozygous sickle-cell anaemia (n= 6) and sonographically characterized by a small or normal sized spleen (n = 6), with diffuse enhanced echogenicity (n= 8), and foci with diminished echogenicity (n=5). Type II morphology (n = 6) was predominantly found in myeloproliferative diseases (n = 4) and characterized by an enlarged spleen with a homogeneous echotexture (n = 7), and a solitary (n = 6), triangular (n=4), hyperechoic (n=4) splenic foci near the splenic surface. On CDS CI were characterized by absent flow signals (n = 7) or by reduced flow signals (n= 7). Spontaneous splenic ruptures occurred as infarction related complications in 3 of 14 cases (21%). CI develops in 17.5% of patients with infarctions. It occurs predominantly in patients with sickle-cell anaemia and myeloproliferative disease. Two characteristic morphologic patterns were found and associated with an increased risk of spontaneous splenic rupture: Therefore sonographic follow-ups might be useful.

Sonographic appearances of malignant lymphoma of the salivary glands.

We undertook this retrospective study to describe the sonographic findings in patients with malignant lymphoma of the major salivary glands. We reviewed the sonograms and medical records of 7 patients with histologically proven lymphoma of the parotid (3 patients) or submandibular glands (4 patients). Primary lymphoma was found in 1 parotid gland and 2 submandibular glands. The remaining 4 cases were secondary lymphomas. One patient had been diagnosed with Sjögren's syndrome and had been followed up with sonography. In parotid glands, both parenchymal and intraparotid nodal lymphomas were found. All submandibular gland tumors were parenchymal. Intraparotid nodal involvement appeared as multiple small nodules with relatively smooth margins, whereas the parenchymal parotid and submandibular gland lymphomas were larger (25 to 45 mm in longitudinal diameter) and showed various degrees of margin irregularity. All tumors were hypoechoic relative to the normal parenchyma. The primary parotid lymphoma and intraparotid nodal lymphomas had a homogeneous echotexture; the secondary parotid lymphomas and submandibular gland lymphomas were heterogeneous. One submandibular gland lymphoma showed intratumoral echogenic stripes. Neither calcification nor cystic degeneration was observed within the lesions. Lymphomas of the salivary glands present a variety of sonographic appearances, ranging from multiple small, hypoechoic nodules to an irregularly shaped heterogeneous mass without cystic areas or calcifications.

Male splenic-gonadal fusion of the continuous type: sonographic findings

A new case of splenic-gonadal fusion in an 8-year-old boy is reported in which the sonographic findings were highly suggestive to include the condition in the differential diagnosis. A separate mass with medium-level echoes and a homogeneous echo texture, surrounded by a clearly visible echogenic capsule, was found in contact with the lower pole of the left testis. The particular character of this congenital anomaly is emphasized and the pathogenesis, diagnosis, and treatment are discussed.

Accessory spleen: A potential cause of misdiagnosis at EUS

Background: Accessory spleen is a common congenital anomaly. There are currently no endoscopic ultrasound (EUS) criteria for the diagnosis or differentiation of this benign splenic anomaly from pathologic disorders including neoplasms. The purpose of this study was to characterize EUS features and develop criteria for the diagnosis of accessory spleen. Methods: Ten patients undergoing EUS were found to have a possible pancreatic tail or perisplenic mass later confirmed by CT to be either an accessory spleen or a prominent lobule of the spleen. EUS criteria assessed included size, shape, location, echo texture, echo density and border demarcation. Results: Ten patients (mean age 58 years) were evaluated. Indications for EUS were evaluation of pancreaticobiliary disease in 9 patients and a gastric submucosal mass in 1 patient. Eight patients had an accessory spleen and 2 had a lobulated spleen. The mean diameter of these lesions as seen on EUS was 2.70 × 3.12 cm. Nine were round and 1 was oval. Because all were located inferolateral to the pancreatic tail and medial to the spleen, 5 of 10 were initially thought to be pancreatic masses. All of these lesions had a sharp and regular outer margin and homogenous echo texture, 4 were hypoechoic and 6 hyperechoic. There were no specific EUS features identified that differentiated splenic lobulations from accessory spleen. Conclusions: Accessory spleen and splenic lobulation can be misinterpreted as neoplasm by EUS. Although homogenous, they can be hyperechoic or hypoechoic. Their sharp and regular outer margin and anatomic location may help to avoid misdiagnosis. Furthermore, computed tomography may be helpful in confirming their presence.

Role of Transesophageal Endosonography-Guided Fine-Needle Aspiration in the Diagnosis of Lung Cancer

Bronchoscopic methods fail to diagnose lung cancer in up to 30% of patients. We studied the role of transesophageal endosonography (EUS)-guided fine-needle aspiration (FNA; EUS-FNA) in such patients. Prospective study. The final diagnosis was confirmed by cytology, histology, or clinical follow-up. University hospital. Thirty-five patients (30 male and 5 female; mean age, 60.9 years; range, 34 to 88 years) with suspected lung cancer in whom bronchoscopic methods failed. Patients with a known diagnosis, recurrence of lung cancer, or mediastinal metastasis from an extrathoracic primary were excluded. EUS and guided FNA of mediastinal lymph nodes. The procedure was uneventful, and material was adequate in all. The final diagnosis by EUS-FNA was malignancy in 25 patients (11 adenocarcinoma, 10 small cell, 3 squamous cell, and 1 lymphoma) and benign disease in 9 patients (5 inflammatory, 2 sarcoidosis, and 2 anthracosis). Another patient with a benign result had signet-ring cell carcinoma diagnosed on pleural fluid cytology (probably false-negative in EUS-FNA). The sensitivity, specificity, accuracy, and positive and negative predictive values were 96, 100, 97, 100, and 90%, respectively. There were no complications. Reviewing the EUS morphology, the nodes were predominantly located in levels 7 and 8 of American Thoracic Society mediastinal lymph node mapping (subcarinal and paraesophageal region). In seven patients, the punctured nodes were < 1 cm (four malignant and three benign), which are difficult to sample by other methods. The malignant nodes had a hypoechoic, homogenous echotexture. EUS-FNA is a safe, reliable, and accurate method to establish the diagnosis of suspected lung cancer when bronchoscopic methods fail, especially in the presence of small nodes.

Lactating adenoma: US features and literature review.

To describe the ultrasonographic (US) features of adenoma in a lactating breast. The US scans of 11 lactating adenomas in nine patients aged 25-36 years examined in 1991-1996 were retrospectively reviewed. In all lesions, diagnoses were cytologically or histologically proved after US-guided fine-needle aspiration biopsy (eight lesions) or core biopsy (three lesions). Six patients were lactating, and three patients were in the third trimester of pregnancy. The US features analyzed were shape, orientation to the chest wall, border characteristics, echogenicity, homogeneity, enhancement or shadowing, and depth within the breast. Most lesions had benign US features such as ovoid shape with the long axis parallel to the chest wall (10 of 11), well-defined margins (eight of 11), homogeneous echotexture (eight of 11), and posterior acoustic enhancement (10 of 11). Four lesions had US features that resembled malignant lesions, such as irregular margins, heterogeneous echotexture, and posterior acoustic shadowing. The US features, although generally benign, are not specific. Tissue sampling with fine-needle aspiration biopsy is recommended. Core biopsy is necessary if a diagnosis cannot be made with the aspirate but is not performed initially because of the possibility of milk fistula formation.

Maturation of the testis: Ultrasound evaluation

We performed a prospective study to investigate whether the sonographic appearance of the testicular parenchyma changes during maturation of the testis. One hundred forty-three boys ranging in age from 6 months to 16 years, and 11 volunteers aged about 30 years, were included in the study. The echogenicity of each of the 308 normal testes was determined by measuring the average brightness of a histogram over a defined testicular area. To avoid divergent results due to different settings of the device in individual cases, the average brightness of a histogram of a standard ultrasound phantom was measured immediately after the examination of each testicle. From these 2 measurements, testicular echogenicity could be calculated independently of individual equipment settings. All testes had a homogeneous echotexture. The echogenicity of the prepubertal testis was markedly reduced compared to the medium-level echogenicity of the mature testis ( p < 0.001). Testicular echogenicity increases during puberty. We conclude that testicular echogenicity increases with maturation. Knowledge of this fact may improve the diagnostic performance of scrotal ultrasound especially in children.

Amyloidosis of the thyroid gland: Role of ultrasonography

We studied the role of ultrasound assessment of the thyroid gland in detecting amyloid deposition in 9 patients confirmed to have renal amyloidosis because the thyroid gland is a readily accessible organ. Ultrasound examination of the thyroid gland showed a distinctive abnormal appearance in 7 patients. There was enlargement of one or both lobes of the thyroid, a high echogenicity approaching that of the surrounding connective tissue, and a very fine homogeneous echotexture similar to ground glass appearance. Four patients showed dilated follicles in the thyroid gland. The other two patients had normal ultrasound findings. Open wedge biopsy of the thyroid gland in 4 patients, (3 with abnormal ultrasound findings and 1 with normal ultrasound findings) showed amyloid deposits in the 3 patients with abnormal echo findings and no amyloid deposits in the 1 patient with normal findings. In 10 healthy individuals, 10 patients who were just initiated on maintenance hemodialysis and another 10 patients on dialysis for more than 1 year, the thyroid gland was of normal size and appearance in the ultrasound examination. We conclude that ultrasound examination by an experienced radiologist is a useful tool in the diagnosis of thyroid amyloidosis.

Sonographic appearances of superficial soft tissue lipomas.

High-resolution real-time sonography was used to evaluate 35 superficial soft tissue lipomas. Thirty were located in subcutaneous tissues and 5 in superficial muscles. The lipomas were assessed for location, shape and size, boundaries, echotexture, homogeneity, and sound through transmission. All were elongated, with their greatest diameter parallel to the skin. Twenty-three lipomas (66%) showed a homogenous echotexture. Twenty-one (60%) were well defined, and the remainder showed ill-defined margins blending into the surrounding tissues. Twenty-nine percent of the lipomas were hypoechoic, 22% were isoechoic, 29% were hyperechoic, and 20% showed a mixed pattern. An elongated isoechoic or echogenic mass in the subcutaneous tissues should suggest the diagnosis of lipoma.