Hyperechoic Foci Research Articles

Advancements in Ultrasound Diagnosis of Superficial Endometriosis: Current Challenges and Emerging Techniques.

Endometriosis is a chronic disease characterized by endometrial-like tissue outside the uterus. Superficial endometriosis (SE) is the most prevalent form, yet it remains underdiagnosed due to subtle clinical and imaging presentations. Traditionally, diagnosis relies on laparoscopy, which is relatively invasive and often contributes to diagnostic delay. With advancements in imaging techniques, especially transvaginal ultrasound (TVS), a reassessment of the diagnostic approach for SE is needed. This review updates the understanding of SE diagnostics and integrates both historical perspectives and contemporary clinical insights. The review aims to explore advancements in the diagnosis of SE, focusing on the growing role of TVS as a non-invasive diagnostic tool. Additionally, it seeks to highlight emerging diagnostic challenges and present new approaches to managing SE to offer updated recommendations for clinicians. A comprehensive literature search was conducted using PubMed, MEDLINE, and Google Scholar. The following keywords were used: "superficial endometriosis," "diagnostic pathways," "endometriosis diagnosis," "superficial lesions," "transvaginal ultrasound," "laparoscopy," "non-invasive imaging," and "diagnostic accuracy." Only English-language articles were included, focusing on original research, metanalyses, and clinical guidelines, offering historical and current perspectives. In addition to the literature review, contemporary insights were gathered from our clinical practice at a tertiary endometriosis clinic to offer real-world context to the literature findings. The review highlights TVS as a promising non-invasive method for diagnosing SE. While SE has historically been diagnosed through laparoscopy, TVS is gaining recognition as a valuable tool for detecting SE lesions, particularly through the identification of key sonographic features such as hyperechoic foci and cystic spaces. These advancements help overcome the challenges posed by the variability of SE presentation on imaging. Emerging techniques, such as SPG (sonoPODography), further enhance SE diagnosis and offer the potential for broader clinical application. Despite challenges such as the need for operator expertise and variability in lesion presentation, the literature and clinical insights support the growing utility of TVS in diagnosing SE. TVS has significant potential as a non-invasive diagnostic tool for SE. While limitations such as variability in sensitivity and the need for operator expertise remain, TVS can significantly reduce reliance on invasive methods like laparoscopy. Additionally, the review provides insights into managing cases where TVS results are negative for SE. In such cases, clinicians must adopt a patient-centred approach that emphasizes symptom management, patient autonomy, and education about possible risks and treatment options. Rather than defaulting to a 'watchful waiting' or a "one size fits all" strategy, it is essential to engage patients in shared decision-making, allowing them to make informed choices about further diagnostic or therapeutic interventions. This review underscores the importance of integrating TVS into routine diagnostic pathways for SE, improving early detection and enhancing patient care. Future research should focus on refining TVS techniques, establishing standardized diagnostic criteria, and exploring alternative diagnostic strategies for patients with negative imaging results. This approach has the potential to shift the paradigm of SE management, reducing diagnostic delays and empowering patients with a more proactive, informed approach to their care.

Validation of ACR TI-RADS performance in transition age: results from a multicenter retrospective study by the TALENT study group.

Although thyroid nodules are less common in the pediatric population, the risk of malignancy is higher than in adult patients. The aim of this study was to evaluate the ultrasonographic predictive factors of malignancy in thyroid nodules and to validate American College of Radiologists (ACR) TI-RADS performance in transition age patients. One hundred forty-two patients aged between 14 and 21 years referred to the participating centers for FNA biopsy of a thyroid nodule between 2007 and 2022 were included and ultrasound reports and sonographic images were retrospectively analyzed. Nodule features were defined according to the ACR-TIRADS lexicon. Two reference standards were applied: FNA cytology and surgical histology. The diagnostic performance of single sonographic features was estimated. Significant predictors were then included in a multivariate regression model. Nodules included in ACR-TIRADS categories TR4 or TR5 had 10-fold increased risk of indeterminate or suspicious/malignant cytology [p < 0.001]. In univariate analysis, solid composition [p = 0.016] and presence of hyperechoic foci [p = 0.040] significantly increased the likelihood of malignant histology. In multivariate regression analysis, irregular margins [p = 0.011] and hyperechoic foci [p = 0.019] were independent predictors of indeterminate or suspicious/malignant cytology. Nodules included in ACR-TIRADS categories TR4 or TR5 had 10-fold increased risk of indeterminate or suspicious/malignant cytology in transition age. ACR-TIRADS was not able to rule-out malignancy compared to FNAB alone, suggesting the need to reconsider recommendations in the transition age group.

Bilateral Dermoid Ovarian Cysts in a Young Woman - A Case Report and Literature Review.

Ovarian tumors are a common type of neoplasm in women, with mature cystic teratomas being the most frequent variant. These tumors occur bilaterally in approximately 10% of cases. However, bilateral and multiple occurrences are rarely reported. A 22-year-old nulliparous woman presented with amenorrhea and sudden, generalized, dull lower abdominal pain. Diagnostic imaging, including ultrasound and computed tomography (CT) scans, revealed large solid-cystic lesions in both ovaries, with internal hyperechoic foci consistent with fat and calcification, along with thin internal septations. A laparoscopic cystectomy was successfully performed, preserving ovarian function. Histopathological examination confirmed the presence of stratified keratinized squamous epithelium, sebaceous glands, hair follicles, mature adipose tissue, blood vessels, and lymphatic vessels within the resected cysts, with no evidence of malignancy. This unique case provides valuable insights into the understanding and management of bilateral dermoid cysts, highlighting the importance of preserving ovarian function in young women.

Sonographic findings associated with complications in pediatric patients with septic arthritis.

Ultrasound is a valuable tool for diagnosing septic arthritis and guiding the development of treatment plans. This study aimed to identify sonographic findings associated with complications in septic arthritis. Twelve patients aged <5 years diagnosed with septic arthritis were classified into two groups: those with and without complications. Complications were defined as the destruction of the epiphyseal bone head and metaphysis bone cortex. The following sonographic findings were compared between the two groups using Fisher's exact test: synovial membrane thickness, joint effusion, diminished hyperechoic foci within the epiphyseal bone head, and diminished smooth metaphyseal bone cortex. Overall, 4 of 12 patients developed complications. Joint effusion and synovial membrane thickening were detected in all patients with septic arthritis. The incidence of diminished hyperechoic foci within the epiphyseal bone head was significantly different between the two groups (presence/absence in patients with complications vs. without = 3/1 vs. 0/8, p = 0.018). The incidence of diminished smooth metaphyseal bone cortex was higher in patients with complications than in those without; however, this difference was not statistically significant (presence/absence in patients with complications vs. without = 4/0 vs. 3/5, p = 0.081). Ultrasound proved to be an effective diagnostic tool for septic arthritis and also demonstrated its potential in predicting complications of septic arthritis in the pediatric population.

Relationship between bull signalment and testicular attributes in a Kenyan bull station.

Male fertility is essential to bovine reproduction, particularly when bulls are used for artificial insemination or single-sire breeding. Bull breeding and soundness examinations (BBSE) are routinely undertaken to identify potentially unfit bulls for breeding. Multiple criteria, including physical examination and determination of testicular and semen parameters, characterize BBSE. Knowledge interstices within this realm, especially in tropical African settings, necessitate pragmatic approaches to address the same. This study aimed to investigate the potential effects of bull parameters on testicular attributes in a tropical setting. The present study recruited healthy bulls (n = 96) aged >16 months with active semen collection used for artificial insemination at the Kenya Animal Genetic Resources Center. The breed breakdown was as follows: Ayrshire (n = 40), Boran (n = 3), Friesian (n = 36), Guernsey (n = 5), Jersey (n = 7), and Sahiwal (n = 5). Age, breed, body weight, scrotal circumference (SC), and testicular echotexture were collected, and the findings were analyzed using R statistical software. SC increased with age and body weight (p < 0.0001). SC varied from one breed to the others (p < 0.0001). Furthermore, as determined using trans-scrotal ultrasonography, hyperechoic testicular lesions were present in 30.21% of the bulls imaged, and the incidence was significantly related to age (p < 0.001). SC is significantly affected by age and body weight. The mean SC was higher in the Bos indicus, but this finding is only indicative because the Sahiwal and Boran sample sizes were small. Notably, the prevalence of hyperechoic testicular foci following trans-scrotal ultrasonography was common in older bulls. However, there is a need to further elucidate this phenomenon's pathophysiology with age as the etiology and possible sequelae of semen quality.

MRI and Ultrasound Visualization of a Nerve Repair Implant Containing Nitinol.

Nerve Tape is a novel nerve repair device containing nitinol microhooks that provide sutureless attachment for nerve coaptation. This study evaluated visualization of Nerve Tape on magnetic resonance imaging (MRI) and ultrasound, with the objective of exploring its potential as an imaging marker for localizing nerve repair sites. Phantom imaging experiments were first conducted to assess the visibility of Nerve Tape on MRI and ultrasound. A cadaveric limb investigation was then performed to further characterize the magnetic susceptibility patterns of Nerve Tape and to confirm its localization at the repair site. Phantom imaging experiments demonstrated clear visualization of Nerve Tape on both MRI and ultrasound, with Nerve Tape microhooks appearing as signal voids on MRI and hyperechoic foci on ultrasound. Subsequent cadaveric limb investigation further characterized Nerve Tape's magnetic susceptibility patterns and confirmed localization of the device at the repair site. The physical dimensions of Nerve Tape and locations observed on both MRI and ultrasound matched design and measurements made during surgery. Measurement discrepancies could be attributed to magnetic susceptibility artifacts in MRI, and to comet tail and shadowing effects in ultrasound. Repairs performed with Nerve Tape can be reliably localized for imaging, potentially facilitating assessment of repair site integrity and further advancement toward image-based monitoring of nerve regeneration. Further research, including in vivo human studies, is warranted to confirm these preliminary findings.

Visualizing thyroid health: a pictorial journey through 2017 ACR TI-RADS and common thyroid pathologies.

With the advent of high-resolution ultrasonography (HRUS), more thyroid nodules are being detected than ever before, and they are being identified at an earlier stage. It poses a challenge for radiologists and clinicians in deciding what to do next. Most nodules are benign and require no follow-up and intervention. Even highly suspicious nodules can be followed up, if the size is small. Variations in HRUS interpretation among radiologists are common, with frequent misidentifications between spongiform and solid-cystic lesions, hypoechoic and very hypoechoic nodules, and microcalcification and hyperechoic foci with comet-tail artifacts. Cystic lesions with echogenic contents are often confused with solid nodules, cystic papillary carcinoma thyroid is often confused with colloid cysts. The 2017 ACR TI-RADS (American College of Radiology Thyroid Imaging Reporting and Data System) aims to standardize the interpretation of thyroid nodules and guide further management. Rather than giving specific diagnosis like colloid cyst, adenomatous nodule and papillary carcinoma; ACR TI-RADS classifies nodules from TI-RADS 1 to TI-RADS 5 based on HRUS characteristics and recommends further management. What the authors often read are textual contents that are theoretical, and in practice, the authors get confused while interpreting the characteristics of thyroid nodules. This review offers a detailed visual overview of the 2017 ACR TI-RADS and common thyroid conditions, explaining key features through imaging data and examples for consistent interpretation. Combining textual explanations with visual aids, this article provides practical guidance for interpreting thyroid nodules for radiologists, and clinicians seeking a clear understanding of thyroid imaging and pathology.

Ultrasonography of the suspensory ligament branches in yearling and 2-year-old Thoroughbred sales horses: Prevalence, progression of findings and associations with racing performance.

Equine suspensory ligament branch (branch) ultrasonography is becoming increasingly commonplace presale. No ultrasonographical branch reference data exists for Thoroughbred sales horses. To define the prevalence of ultrasonographical findings in the forelimb suspensory branches of yearling and 2-year-old sales Thoroughbreds and to analyse associations with racing performance. To track changes in branch findings between 1 and 2 years of age in horses that present for sale at both ages. Prospective cohort study using an enrolled sample. Horses were enrolled from a 2016 yearling sale and five 2017 2-year-old sales with consignor permission. Ultrasonography was performed immediately prior to the sales. Ultrasonographical findings relating to branch size, fibrillar pattern, the presence of hyperechoic foci, periligamentar tissue thickness and the adjacent proximal sesamoid bone surface were examined. Associations with racing performance from 2 to 4 years of age were investigated using multivariate regression analyses. Clinical follow-up was sought to ascertain why horses that did not race never started. A total of 593 sales yearlings and 367 2-year-olds had forelimb branch ultrasonography performed. Grade ≥2 fibrillar branch change was present in 8.9% of yearlings and 14.4% of 2-year-olds. A 0.25 cm increase in branch width was associated with a 49-day delayed start to racing careers (P < 0.001, 95% confidence interval (95% CI): 21-77 days). The presence of grade 2 hyperechoic foci was associated with significantly lower total earnings (P = 0.01, 95% CI: $2000-$16 022) and lower earnings per start (P = 0.003, 95% CI: $349-$1718) in United States Dollars. Grade 3 fibrillar branch change had clinically important reductions in the probability of racing, the calibre of racing performance and earnings. Grade 1 fibrillar pattern was associated with significantly higher earnings per start (P = 0.004, 95% CI: $2641-$5759). The findings are applicable to horses prepared for public auction and deemed fit to be entered for sale. The results may underestimate the proportion of severe lesions in horses not entered for sale. Reference values specific to young Thoroughbreds have been established. Grade 1 fibrillar branch change should be regarded as an acceptable appearance in sales yearlings and 2-year-olds. Approximately one-third of grade 2 yearling branches progressed to a grade 3 lesion. Evidence of enlarged branch width and grade 2 hyperechoic foci at 2-year-old sales constitute a risk to racing performance.

Cervicofacial Actinomycosis: Detection and follow‐up through ultrasound image

AbstractAimTo demonstrate a case of Actinomyces infection in which ultrasound was used as a diagnostic aid tool.Materials and MethodsDescription of a case of cervicofacial actinomycosis in a patient, whose treatment and long‐term evaluation were performed using ultrasound, a crucial tool to ensure accuracy and real‐time images, without exposing the patient to radiation, contributing to the success of treatment.ResultsIn the case of actinomycosis, the ultrasound findings consisted of hyperechoic foci surrounded by hypoechoic areas.ConclusionsUltrasonography plays a broad role in dentistry, being able to assist in diagnosis, guided surgical interventions and post‐treatment monitoring. Furthermore, ultrasound is an accessible and portable examination that can be used at the patient's bedside, especially in critical cases, proving to be a promising tool in clinical management in a hospital environment.

Using Point-of-care Ultrasonography to Diagnose Traumatic Arthrotomy of the Knee: A Case Series.

Accurate diagnosis of traumatic arthrotomy of the knee (TAK) is critical for patients presenting to the emergency department (ED) to ensure timely treatment. Current diagnostic modalities including plain radiography, computed tomography (CT), and the saline load test (SLT) have advantages and disadvantages. Point-of-care-ultrasonography (POCUS) offers a possible timely, low-cost, and efficient alternative method of diagnosing TAK. In this case series we present three cases where POCUS was used to diagnose TAK in the ED. Three patients in their early 20s presented to the ED complaining of knee trauma with wounds in proximity to the joint. Mechanisms of injury included a gunshot wound in one case and blunt trauma (motor vehicle collision and bicycle crash) in two cases. In all three cases TAK was suggested on POCUS examinations by the presence of intra-articular hyperechoic foci consistent with air artifact. All three cases had TAK confirmed by orthopedic evaluation. Ultrasound may have utility in the evaluation of patients presenting with knee trauma where TAK is a concern. The SLT is generally considered the gold standard test for diagnosis of TAK, but it is invasive and has a wide range of diagnostic accuracy. Intra-articular air has been found to be a sensitive marker for TAK in CT studies. Thus, additional investigations into the diagnostic accuracy of POCUS for this finding should be undertaken.

Value of 2D ultrasonography in the diagnosis and evaluation of intrauterine adhesions – a prospective study

Research questionWhat is the value of 2D ultrasonography in the diagnosis and assessment of intrauterine adhesions (IUA)? DesignThis was a prospective study conducted at a hysteroscopy centre. ResultsOf a total of 600 subjects recruited, 41 dropped out and 559 were finally enrolled and analysed. The observed 2D ultrasonography features, in decreasing order of frequency, were ‘irregular endometrium’ (37.9%), ‘broken endometrial echo’ (23.4%), ‘thin endometrium’ (13.7%), ‘loss of endometrial echo’ (13.1%,), ‘hyperechoic focus’ (12.5%) and ‘fluid in the cavity’ (8.8%). The sensitivity of individual ultrasound features ranged from 8.8% to 37.9%, whereas the specificity of individual ultrasound features ranged from 78.9% to 100%. When all the six ultrasound features were considered together, the sensitivity and specificity were 71.7% and 66.2% respectively. The sensitivity, specificity and accuracy of ultrasound diagnosis in the mid-proliferative phase, peri-ovulatory phase and mid-luteal phase did not appear to be significantly different statistically, although the results in the mid-proliferative phase appeared to be consistently higher than those in the mid-luteal phase. In women confirmed to have IUA, the likelihood of the adhesions being severe in nature in the presence of zero, one, two or three or more ultrasound features was 8.7%, 23.0%, 40.2% and 80.5%, respectively (P < 0.001). ConclusionsThe findings in this study support the notions that ultrasonography examination in women suspected to have IUA cannot replace hysteroscopy in the diagnosis of the condition. However, it does provide useful clinical information regarding severity and could help in the planning of hysteroscopy to optimize management.

Multimodal ultrasound techniques for the differential diagnosis of splenic lesions - Adiagnostic challenge

Splenic tumors are rare and can pose adifferential diagnostic challenge, especially as an incidental imaging finding. Due to alack of large scale biopsy studies the available literature is limited with respect to clear imaging criteria for dignity. The present work is intended to show the chances of atargeted elicitation of the medical history as well as the possibilities and limitations of multimodal sonography in order to achieve the correct diagnosis of asplenic lesion using simple and gentle methods. Selective literature search and clinical case studies. In the differential diagnostics of focal splenic lesions, information about pre-existing hemato-oncological or inflammatory rheumatological diseases is essential in order to correctly classify incidental findings in particular. In addition to B‑mode ultrasound (B-US) and color-coded Doppler ultrasound (CD-US), contrast-enhanced ultrasound (CEUS) in particular provides crucial differential diagnostic information. While hyperechoic foci in B‑US or arterially hypervascularized splenic foci in CD-US/CEUS are usually benign, hypoechoic and arterially hypoperfused foci in CD-US/CEUS must be further clarified. Although the ultrasound-guided biopsy of the spleen has ahigher risk of bleeding than aliver biopsy, it is still the gentlest and most effective method for achieving the histological clarification of splenic lesions when the indications are correct. Through the combination of the medical history and multimodal ultrasound methods, if necessary supplemented by anultrasound-guided biopsy, focal splenic lesions can be successfully classified in most cases with adirect impact on further clinical procedures.

Ultrasound‐guided modified subcostal transversus abdominis plane block in a foal undergoing omphalectomy

SummaryA 7‐day‐old, 60 kg, Purebred Spanish Horse filly was referred with the mare to Complutense University of Madrid, Veterinary teaching hospital for elective omphalectomy. Upon admission, clinical examination was unremarkable except for a thickening of the umbilical area. Haematology and biochemistry values were within the normal range. On abdominal ultrasound (US) examination, a well‐defined, rounded (24 mm of diameter) area that contained heterogeneous material with numerous hyperechoic foci with acoustic shadowing was seen within the inner portion of the umbilical pedicle, between both umbilical arteries. Surgical correction with omphalectomy was scheduled. To provide perioperative analgesia, the transversus abdominis plane (TAP) block was considered. Under general anaesthesia, TAP block was performed in both left and right hemi‐abdominal walls with a modified subcostal approach with two‐site injections. A spinal needle was inserted under US guidance. During surgery, end‐tidal concentration of isoflurane was maintained at 0.7%–0.9%. Surgery was completed uneventfully and no signs of nociceptive input were observed, suggesting an adequate level of analgesia. Therefore, this TAP block technique may be considered to provide analgesia for surgical procedures involving the abdominal wall in foals.

A survey of testicular texture in canine ultrasound images.

Computer-based texture analysis provides objective data that can be extracted from medical images, including ultrasound images. One popular methodology involves the generation of a gray-level co-occurrence matrix (GLCM) from the image, and from that matrix, texture fractures can be extracted. We performed texture analysis on 280 ultrasound testicular images obtained from 70 dogs and explored the resulting texture data, by means of principal component analysis (PCA). Various abnormal lesions were identified subjectively in 35 of the 280 cropped images. In 16 images, pinpoint-to-small, well-defined, hyperechoic foci were identified without acoustic shadowing. These latter images were classified as having "microliths." The remaining 19 images with other lesions and areas of non-homogeneous testicular parenchyma were classified as "other." In the PCA scores plot, most of the images with lesions were clustered. These clustered images represented by those scores had higher values for the texture features entropy, dissimilarity, and contrast, and lower values for the angular second moment and energy in the first principal component. Other data relating to the dogs, including age and history of treatment for prostatomegaly or chemical castration, did not show clustering on the PCA. This study illustrates that objective texture analysis in testicular ultrasound correlates to some of the visual features used in subjective interpretation and provides quantitative data for parameters that are highly subjective by human observer analysis. The study demonstrated a potential for texture analysis in prediction models in dogs with testicular abnormalities.

Ultrasonographic features of a histologically confirmed pilomatricoma in a dog

AbstractA 6‐year‐old, neutered, crossbreed, female dog was presented for a well‐defined subcutaneous mass on the head evolving for a year. An ultrasound exam revealed a well‐circumscribed, oval, heterogeneous and hyperechoic soft tissue mass, with hyperechoic internal foci, a hypoechoic peripheral rim, a cystic fluid component and a high vascularisation in colour Doppler. An isolated hair was also detected and removed from the fluid component. The mass was sampled and histological examination suggested a benign pilomatricoma. The owner declined further investigation and complete resection of the mass. This is the first report of ultrasonographic features of a pilomatricoma in a dog.

Association between the dynamic movement of hyperechoic foci and patients'/sonographic outcomes among pediatric patients with portal venous gas following a cardiac event.

To demonstrate the association between the dynamic movements of hyperechoic foci in portal venous gas (PVG) and patients'/sonographic outcomes after congenital heart disease or cardiac events. Thirty-one pediatric patients requiring management of congenital heart diseases or cardiac events who had PVG on ultrasound were included in this retrospective study. The patient outcome was prognosis: dead or alive. The sonographic outcome was recovery from PVG, measured as days from PVG detection to when it diminished on ultrasound. The following sonographic findings of hyperechoic foci in PVG were compared between patients: detection within the mesenteric vein, having to-and-fro movements within the intrahepatic portal vein, distribution (left segment or both left and right segments) and shape (line or punctate) in the liver, and detection within the portal and hepatic veins. Comparisons were made using Fisher's exact/Mann-Whitney U test. Four patients died without having recovered from PVG. A significant difference was observed in terms of the to-and-fro movement (with/without to-and-fro movement in dead vs. alive patients: 3/1 vs. 1/26, respectively; P = 0.003). Furthermore, a significant difference in sonographic outcomes was observed regarding patients with/without hyperechoic foci within the mesenteric vein (days with vs. without this finding: 2.0 ± 1.24(1-5) vs.1 ± 0(1), respectively; P = 0.011). In our small limited cohort, when PVG was visualized on ultrasound, close evaluation of the dynamic movement of hyperechoic foci, especially their to-and-fro movement within the intrahepatic portal vein and detection of hyperechoic foci within the mesenteric vein, were useful in predicting patients' outcomes and the time to PVG diminishment.

Superficial Endometriosis at Ultrasound Examination-A Diagnostic Criteria Proposal.

The actual prevalence of superficial endometriosis is not known. However, it is considered the most common subtype of endometriosis. The diagnosis of superficial endometriosis remains difficult. In fact, little is known about the ultrasound features of superficial endometriotic lesions. In this study, we aimed to describe the appearance of superficial endometriosis lesions at ultrasound examination, with laparoscopic and/or histologic correlation. This is a prospective study on a series of 52 women with clinical suspicion of pelvic endometriosis who underwent preoperative transvaginal ultrasound and received a confirmed diagnosis of superficial endometriosis via laparoscopy. Women with ultrasound or laparoscopic findings of deep endometriosis were not included. We observed that superficial endometriotic lesions may appear as a solitary lesions, multiple separate lesions, and cluster lesions. The lesions may exhibit the presence of hypoechogenic associated tissue, hyperechoic foci, and/or velamentous (filmy) adhesions. The lesion may be convex, protruding from the peritoneal surface, or it may appear as a concave defect in the peritoneum. Most lesions exhibited several features. We conclude that transvaginal ultrasound may be useful for diagnosing superficial endometriosis, as these lesions may exhibit different ultrasound features.

A Reappraisal of Suspicious Sonographic Features of Thyroid Nodules: Shape Is Not an Independent Predictor of Malignancy.

For the correct clinical application of the sonographic risk-stratification systems, the definition of independent risk features that are foundational to each system is crucial. The aim of this study was to identify the gray-scale sonographic features independently associated with malignancy, and to compare different definitions. This prospective, diagnostic accuracy study took place in a single thyroid nodule referral center. All patients consecutively referred to our center for fine-needle aspiration cytology of a thyroid nodule between November 1, 2015 and March 30, 2020, were enrolled before cytology. Each nodule was examined by 2 experienced clinicians to record the sonographic features on a rating form. Histologic (when available) or cytologic diagnosis was used as the reference standard. For each single sonographic feature and definition, the sensitivity, specificity, positive and negative predictive values, and diagnostic odds ratios (DOR) were calculated. The significant predictors were then included in a multivariable regression model. The final study cohort consisted of 903 nodules in 852 patients. A total of 76 nodules (8.4%) were malignant. Six features were independent predictors of malignancy: suspicious lymph node (DOR 16.23), extrathyroidal extension (DOR 6.60), irregular or infiltrative margins (DOR 7.13), marked hypoechogenicity (DOR 3.16), solid composition (DOR 3.61), and punctate hyperechoic foci (including microcalcifications and indeterminate foci; DOI 2.69). Taller-than-wide shape was not confirmed as an independent predictor. We identified the key suspicious features of thyroid nodules and provided a simplified definition of some debated ones. Malignancy rate increases with number of features.

An uncommon cause of pancreatitis with obstructive jaundice

A 56-year-old man with a history of diabetes mellitus poorly controlled recently (HbA1c: 7.5%, <6%) presented with a 3-month history of postprandial epigastric pain, 10-kg weight loss, steatorrhea, tea-colored urine, and clay-colored stool. Physical examination revealed yellowish skin and icteric sclera but no peripheral stigmata of cirrhosis. Laboratory investigation was significant for elevated aspartate aminotransferase (289 IU/L, 8-31 IU/L), alanine aminotransferase (613 IU/L, 0-41 IU/L), alkaline phosphatase (595 U/L, 34-104 U/L), γ-glutamyl transferase (758 U/L, 0-26 U/L), total and direct bilirubin (8.0/6.1 mg/dL, 0.3-1/0.03-0.18 mg/dL), and carbohydrate antigen 19-9 (289 U/mL, <37 U/mL). Contrast-enhanced computed tomography revealed diffuse enlargement of the pancreas (arrow) and dilatation of the common bile duct (CBD) without identifiable stone or a mass lesion (arrowhead; Figure 1A). Endoscopic ultrasound (EUS) demonstrated hyperechoic foci and strands in the enlarged pancreas (arrow) and layer-by-layer whole wall thickening with a hyper-hypo-hyperechoic series (sandwich pattern) of CBD (arrowhead) as well as gallbladder (star; Figure 1B). Magnetic resonance cholangiopancreatography (MRCP) showed dilated CBD with distal tapering near the pancreatic head (arrow; Figure 1C). The diagnosis of autoimmune pancreatitis was confirmed by serologic immunoglobulin G4 (IgG 4) elevation (IgG 4: 2880 mg/dL, 3-201 mg/dL) and favored type I according to nonductal Level 1/Level 2 criteria of international consensus diagnostic criteria.1 The patient recovered from jaundice and gained weight after treatment of prednisone 40 mg/d for 4 weeks, then taper by 5 mg/wk. The 8-week follow-up EUS demonstrated normalization of pancreatic size (arrow) and CBD morphology (arrowhead; Figure 2).2 Autoimmune pancreatitis mimicking pancreatic cancer is a rare cause of obstructive jaundice with an estimated incidence of 1 per 100 000.3 In summary, we demonstrated a case of autoimmune pancreatitis diagnosed by complement image study and elevating serum IgG 4, which achieved successful medical treatment of obstructive jaundice without further invasive procedures.1 The authors declare no conflict of interest. This report was approved by the Research Ethical Committee of Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation (No. CR111-08).

First Trimester Ultrasound Detection of Fetal Central Nervous System Anomalies.

To evaluate the potential of the first-trimester ultrasound (US) features for the detection of central nervous system (CNS) anomalies. Methods/Methodology: This is a prospective one-center three-year study. Unselected singleton pregnant women were examined using an extended first-trimester anomaly scan (FTAS) that included the CNS assessment: the calvaria shape, the septum (falx cerebri), the aspect of the lateral ventricles, the presence of the third ventricle and aqueduct of Sylvius (AS) and the posterior brain morphometry: the fourth ventricle, namely intracranial translucency (IT), brain stem/brain stem-occipital bone ratio (BS/BSOB) and cisterna magna (CM). The spine and underlying skin were also evaluated. The cases were also followed during the second and third trimesters of pregnancy and at delivery. FTAS efficiency to detect major CNS abnormalities was calculated. We detected 17 cases with CNS major abnormalities in a population of 1943 first-trimester (FT) fetuses, including spina bifida with myelomeningocele, exencephaly-anencephaly, holoprosencephaly, hydrocephaly, cephalocele and Dandy-Walker malformation. The CNS features in the abnormal group are presented. In the second trimester (ST), we further diagnosed cases of corpus callosum agenesis, cerebellar hypoplasia, vein of Galen aneurysm and fetal infection features (ventriculomegaly, intraventricular bands, intraventricular cyst and hyperechoic foci), all declared normal at the FTAS. During the third trimester (TT) scan we identified a massive fetal cerebral haemorrhage absent at previous investigations. We report a detection rate of 72.7% of fetal brain anomalies in the FT using the proposed CNS parameters. The sensitivity of the examination protocol was 72.7%, and the specificity was 100%. A detailed FT CNS scan is feasible and efficient. The majority of cases of major CNS abnormalities can be detected early in pregnancy. The visualization rates of the CNS parameters in the FT are great with short, if any, additional investigation time. FT cerebral disorders such as haemorrhage or infections were missed in the FT even when an extended evaluation protocol was used.