Limitations Of Ultrasonography Research Articles

Neuroimaging Markers for Differential Diagnosis Between Multifocal Motor Neuropathy and Multifocal Acquired Demyelinating Sensory and Motor Neuropathy

Introduction. Similar asymmetric patterns of motor disorders and neurophysiological changes complicate the differential diagnosis between multifocal motor neuropathy (MMN) and multifocal acquired demyelinating sensory and motor neuropathy (MADSAM) as two chronic dysimmune neuropathies with significantly different treatment approaches. The lack of specific paraclinical markers often result in misdiagnosis and selection of ineffective specific therapy. Identification of specific neuroimaging biomarkers to differentiate these conditions may improve diagnostic approaches.
 Objective: To identify neuroimaging markers for the differential diagnosis between MMN and MADSAM.
 Materials and methods. The study included 65 participants, particularly 30 individuals with MMN and 35 individuals with MADSAM followed up in the Center of Peripheral Nervous System Diseases, Research Center of Neurology, Moscow, Russia. We retrospectively analyzed their clinical and epidemiological characteristics as well as ultrasonography and magnetic resonance imaging (MRI) findings.
 Results. Ultrasonography was performed on the peripheral nerves of the upper extremities, the spinal nerves, and the brachial plexus. The results showed that participants with MADSAM had significantly greater cross-sectional areas (CSAs) and a higher incidence of intraneural ultrasonographic abnormalities compared to participants with MMN. CSA thresholds of the median nerves were identified using ROC analysis to differentiate between MMN and MADSAM. MRI scans of the brachial plexus revealed no abnormalities in 41.4% of the individuals with MMN and 27.3% of the individuals with MADSAM. Meanwhile, STIR hyperintense signal from the brachial plexus was most typical ( 70%) for the MADSAM group.
 Conclusions. This was the first detailed comparative analysis of neuroimaging findings in a large sample of patients with either MMN or MADSAM in Russia. Ultrasonographic markers for differential diagnosis have been determined. The advantages and limitations of ultrasonography and MRI of the brachial plexus and the spinal and peripheral nerves in diagnosing multifocal chronic dysimmune neuropathies have been demonstrated.

A case of Marine Lenhart syndrome with Hashimoto’s thyroiditis that mimicked thyroid carcinoma

BackgroundMarine Lenhart syndrome is a rare disease and causes refractory hyperthyroidism. So far, little evidence on the combination of both Marine Lenhart syndrome and Hashimoto's thyroiditis is available. We suspect that Marine Lenhart syndrome when combined with Hashimoto's thyroiditis might have its particular features, which are not exactly the same as those of the isolated Marine Lenhart syndrome.Case presentationA 56-year-old middle-aged man presented with recurrent hyperthyroidism, and Graves' disease combined with Hashimoto's thyroiditis was considered. Radionuclide imaging showed a hot nodule, but ultrasonography suggested the possibility of malignancy with a category of 4B according to the Chinese-Thyroid Imaging-Reporting and Data System (C-TIRADS) model. Fine needle aspiration cytology (FNAC) revealed eosinophilic follicular lesions with papillary features, and prompted that papillary thyroid carcinoma could not be excluded. Partial thyroidectomy was performed and the nodule was proven to be benign by histopathology. The final diagnosis was atypical Marine Lenhart syndrome with Hashimoto's thyroiditis.ConclusionsMarine Lenhart syndrome combined with Hashimoto's thyroiditis has its particular characteristics, showing some signs mimicking malignancy. Limitations of ultrasonography and FNAC in diagnosis should be noted in these scenarios.

Radiological Imaging in Chest Diseases: Moving Away from Conventional Modes.

A chest radiograph is the most common and the initial radiological investigation for evaluating a child presenting with respiratory complaints. However, performing and interpreting chest radiography optimally requires training and skill. With the relatively easy availability of computed tomography (CT) scanning and more recently multidetector computed tomography (MDCT), these investigations are often performed. Although these can be the cross-sectional imaging modalities of choice in certain situations where detailed and exact anatomical and etiological information is required, both these investigations are associated with increased radiation exposure which has more detrimental effects on children, especially when repeated follow-up imaging is necessary to assess the disease status. Ultrasonography (USG) and magnetic resonance imaging (MRI) have evolved as radiation-free radiological investigations for evaluating the pediatric chest pathologies over the last few years. In the present review article, the utility and the current status, as well as the limitations of USG and MRI for evaluation of pediatric chest pathologies, are discussed. Radiology has grown beyond having just the diagnostic capabilities in managing children with chest disorders in the last two decades. Image-guided therapeutic procedures (percutaneous and endovascular) are routinely performed in children with pathologies in the mediastinum and lungs. The commonly performed image-guided pediatric chest interventions, including biopsies, fine needle aspiration, drainage procedures and therapeutic endovascular procedures, are also discussed in the current review.

Usefulness and Limitations of Ultrasonography as Compared to CT/3D-CT in the Management of Nasal Bone Fractures in Young and Pediatric Patients

CT has become the main imaging modality for nasal bone fractures, and CT is increasingly used even for minor nasal bruising in young and pediatrics patients, increasing their risk of excessive radiation exposure. There are numerous reports of the usefulness of ultrasonography for the diagnosis of nasal fractures, because of the simplicity of this diagnostic tool and avoidance of radiation exposure. In this study, we compared the usefulness of ultrasonography and CT/3D-CT in 13 young and pediatric patients who presented with nasal bruising. The children ranged in age from 5 years 10 months to 17 years 5 months. There were 9 boys and 4 girls; 10 patients had nasal fractures and there were no cases in which nasal fractures could not be confirmed by ultrasonography; 6 cases were judged as requiring repositioning based on the external appearance. The size of the deviated bone and the deviation distance in the cases that required repositioning were larger than those in the cases that did not require repositioning. 3D-CT was the most useful imaging test for nasal fractures. Ultrasonography can be used as a screening tool for young and pediatric patients to avoid radiation exposure. However, it appears to be difficult to make a decision on the need for repositioning using ultrasonography alone.

Value and limitations of sonography in kidney transplant recipients with special attention to the resistive index - An update.

Kidney transplantation has become the standard treatment for end-stage renal disease. Even though the success rates are high, early and late post-transplant complications remain a major clinical problem due to the risk of graft failure. Therefore, it is of highest interest to early diagnose post-transplant complications. Ultrasound with color coded Duplex analysis plays a crucial role in imaging mechanical and vascular complications. In this article, we give an update of the visualizable complications in kidney transplant recipients and discuss the value of resistive index (RI) measurement with its limitations in allograft rejection.

P–679 Magnetic resonance imaging (MRI), an alternative method to evaluate the ovarian reserve

Abstract Study question Is magnetic resonance imaging (MRI) a valid method to access antral follicles count (AFC) compared to two-dimensional (2D) transvaginal ultrasonography (USG) and Anti-Mullerian Hormone (AMH) to evaluate the ovarian reserve? Summary answer AFC has a high agreement between MRI and USG methods, as well as with AMH. MRI can be an alternative method to evaluate ovarian reserve. What is known already In fact, two methods are the most used today to assess ovarian reserve: USG and AMH. The USG is considered the gold standard method for AFC, and contributes to predict and tailor treatment strategies, such as in-vitro fertilization. The major limitations of USG are its user dependency and equipment. Also, there are limitations in displaying a global view of the pelvis and large ovarian lesions. Magnetic resonance imaging (MRI), with its excellent soft-tissue contrast resolution and characteristics, is a useful non-invasive alternative modality to USG. Just one study evaluated MRI and revealed more small size antral follicles compared to 3D-USG. Study design, size, duration A prospective cross-sectional observational study was performed in an assisted reproduction techniques (ART) post-graduation program setting from an assisted reproductive center in Sao Paulo, Brazil, which ran throughout 2019–2020, with a total number of 59 patients that were in fertility treatment and needed to undergo to a MRI procedure to evaluate uterine or pelvic diseases as, Myoma, Adenomyosis, endometriosis, and adnexal cysts. Participants/materials, setting, methods Patients were evaluated to access the AFC by the MRI method and 2D transvaginal USG, and Anti-Mullerian Hormone (AMH) concentration to evaluate the ovarian reserve. Comparison between methods was done through Wilcoxon signed ranks test and Bland-Altman analysis. Ovarian reserve was classified as follows: very low (<4 follicles/AMH<0.5); low (5–7 follicles/AMH=0.5–1.1); normal (8–15 follicles/AMH=1.1–3.5); normal-high (>15 follicles/AMH>3.5). Weighted Cohen’s kappa was used to verify agreement between MRI, USG and AMH classifications of ovarian reserve. Main results and the role of chance Average AFC for USG were 5,55±4.01 for left ovary and 5.55±3.8 for right ovary. Average follicle count for both ovaries was 10±7.07. Regarding MRI, mean counts were 6.44±4.81 for left ovary, 5.65±3.85 for right ovary, and a 11.89±7.89 follicle sum mean count. Average concentration of AMH was 1.79±1.44. The Wilcoxon test and Bland-Altman analyses found differences and systematic biases for comparison between USG and MRI for both ovaries (–2.58; limits of agreement=–14.56 to 9.40, Wilcoxon p = 0,008) and for the right ovary (–1.48; limits of agreement=–8.32 to 5.35, Wilcoxon p = 0,031). There was no difference between methods for the left ovary. Weighted Cohen Kappa coefficients showed substantial agreement between ovarian reserve classifications based on AMH levels, USG, and MRI. The conducted paired comparisons were USG with MRI (k = 0.676), AMH with MRI (k = 0.760) and USG (k = 0.609). Limitations, reasons for caution The systematic biases found when comparing USG to MRI methods may suggest a consistent detection of more follicles with MRI procedures in comparison to the USG method. This bias found warrants caution as it must be confirmed, in future studies. Wider implications of the findings: The MRI method reveals similar ovarian reserve to USG when used the same classification, and a higher agreement to AMH. This suggests that MRI is a reliable method of quantifying antral follicles and can also be adopted when the patient will need to evaluate pelvic pathologies. Trial registration number Not applicable

Adenocarcinoma de colon diagnosticado mediante colonoscopia y tratado con quimioterapia metronómica en un perro

Chronic colitis is the most common cause of chronic hematocheia and dyskinesia in dogs, especially in the elderly. Other causes cannot be ignored, such as: intestinal parasitosis, dysbiosis, endocrinopathies, liver diseases, kidney diseases, dietary intolerances and recklessness, toxicosis, prostatopathies and pancreatic diseases. Faced with the limitation of ultrasonography (descending colon and rectal ampoule being protected by the pelvic case), the importance of videocolonoscopy in this diagnosis is exposed, as well as the mention of neoplastic potential as the basis of the inflammatory process. The purpose of this report is to present a case of colon cancer diagnosed by colonoscopy and which required alternative treatments and follow-up in the absence of surgery.

Diagnostic Accuracy of Ultrasonography for the Assessment of Maxillofacial Fractures: A Meta-analysis.

ABSTRACTObjective:To evaluate the pooled sensitivity and specificity of ultrasonography (USG) in maxillofacial fractures.Materials and Methods:A systematic search was performed in five databases (PubMed, Scopus, CINAHL, Web of Science, Dentistry and Oral Sciences Source) from inception to September 12, 2020. Studies that reported or from which sensitivity and specificity can be calculated and studies published in the English language were included. Conference proceedings, letter to editors, and case reports were excluded. Screening of studies, data extraction, and risk of bias assessment (QUADAS -2) were done separately by two review authors. A bivariate random-effects model was used to calculate the pooled estimates.Results:After the removal of duplicates, 1852 studies were included for screening of title and abstracts. Only 22 studies were included in the quantitative synthesis. The sample size ranged from 6 to 87. The majority of the studies assessed orbit and nasal bones fractures. Only two studies included a comprehensive assessment of facial fractures. The overall sensitivity and specificity values were 0.94 and 0.96, respectively.Conclusion:USG has good diagnostic accuracy for the assessment of fractures of orbit and nasal bones. Clinicians need to consider the advantages and limitations of USG before recommending advanced imaging modalities.

Continued value of the serum alpha-fetoprotein test in surveilling at-risk populations for hepatocellular carcinoma.

Because of the known limitations of ultrasonography (US) alone, we re-evaluated whether complimentary testing for serum alpha-fetoprotein (AFP) is helpful in surveilling for hepatocellular carcinoma (HCC) in high-risk populations. We included, from a hospital-based cancer registry, 1,776 asymptomatic adults who were surveilled biannually with the AFP test and US and eventually diagnosed with HCC between 2007 and 2015. Based on the screening results, these patients were divided into three groups: AFP (positive for AFP only; n = 298 [16.8%]), US (positive for US only; n = 978 [55.0%]), and AFP+US (positive for both; n = 500 [28.2%]). We compared the outcomes of the three groups, calculating the survival of the AFP group both as observed survival and as survival corrected for lead-time. In terms of tumor-related factors, the separate AFP and US groups were more likely to have early stage HCC and to receive curative treatments than the combined AFP+US group (Ps<0.05). The AFP group had significantly better overall and cancer-specific survival than the AFP+US group after adjusting for covariates (adjusted hazard ratios [HRs] 0.68 and 0.62, respectively). In analyses correcting for lead-time in the AFP group (doubling time 120 days), the respective adjusted HRs for the AFP group were unchanged (0.74 and 0.67), but they were no longer significant after additional adjustment for tumor stage and curative treatment (0.87 and 0.81). HCC cases detected by the AFP test without abnormal ultrasonic findings appear to have better survival, possibly as a result of stage migration and the resulting cures. Complementary AFP surveillance, together with US, could be helpful for at-risk patients.

Sonography of musculoskeletal infection in children.

Musculoskeletal infection, especially in young children, often presents with non-specific clinical signs and symptoms necessitating early imaging to identify the source of infection. While MRI is the investigation of choice to demonstrate bone infection, it is expensive and often requires a general anaesthetic in the young child. Ultrasound can be a useful tool in the initial assessment due to its easy availability and portable equipment. It does not involve ionising radiation and is used to guide aspiration and drainage procedures. This review explains sonographic features of septic arthritis, osteomyelitis, pyomyositis and soft tissue infection in children and highlights advantages and limitations of sonography when assessing the child with suspected musculoskeletal infection.

Ultrasonography in Trauma: Physics, Practice, and Training.

* Ultrasonography has gained a unique role in assisting emergency medicine physicians in the trauma setting. Its major advantages include safety, bedside availability, repeatability, and portability. In addition, it does not have to interrupt resuscitation, it does not require sedation, it takes images in real time using multiplanar and nonstandard imaging, and it provides interventional guidance.* Advances in technology have enabled portable ultrasonography devices to offer excellent imaging quality and a quick-start function. In trauma, it can be used in the pre-hospital setting, in disaster situations, during patient retrieval, and in the hospital setting from the emergency department to the operating room, intensive care units, and the wards. It can be used by pre-hospital medical staff, emergency physicians, trauma surgeons, anesthesiologists, radiologists, and sonographers after adequate training.* The limitations of ultrasonography in trauma include the skill of the operators, the need for training and experience, and image artifacts and display.

Placenta increta complicating a second trimester cervical pregnancy: a case report

Abstract Cervical ectopic pregnancy is defined as implantation of the embryo in the endocervical canal below the level of the internal os. It is a rare condition that accounts for 0.15% of all ectopic pregnancies. As it can lead to complications such as uncontrolled hemorrhage, it is associated with high morbidity and mortality. This paper illustrates a rare case of a 2nd trimester cervical pregnancy with failed conservative management due to the limitations of ultrasonography. Successful conservative management requires not only early diagnosis but also usage of other sophisticated techniques such as magnetic resonance imaging (MRI) that can help in detecting adherent placenta.

Magnetic resonance imaging of the fetal brain.

This review covers the recent literature on fetal brain magnetic resonance imaging, with emphasis on techniques, advances, common indications, and safety. We conducted a search of MEDLINE for articles published after 2010. The search terms used were "(fetal OR foetal OR fetus OR foetus) AND (MR OR MRI OR [magnetic resonance]) AND (brain OR cerebral)". Consensus statements from major authorities were also included. As a result, 44 relevant articles were included and formed the basis of this review. One major challenge is fetal motion that is largely overcome by ultra-fast sequences. Currently, single-shot fast spin-echo T2-weighted imaging remains the mainstay for motion resistance and anatomical delineation. Recently, a snap-shot inversion recovery sequence has enabled robust T1-weighted images to be obtained, which is previously a challenge for standard gradient-echo acquisitions. Fetal diffusion-weighted imaging, diffusion tensor imaging, and magnetic resonance spectroscopy are also being developed. With multiplanar capabilities, superior contrast resolution and field of view, magnetic resonance imaging does not have the limitations of sonography, and can provide additional important information. Common indications include ventriculomegaly, callosum and posterior fossa abnormalities, and twin complications. There are safety concerns about magnetic resonance-induced heating and acoustic damage but current literature showed no conclusive evidence of deleterious fetal effects. The American College of Radiology guideline states that pregnant patients can be accepted to undergo magnetic resonance imaging at any stage of pregnancy if risk-benefit ratio to patients warrants that the study be performed. Magnetic resonance imaging of the fetal brain is a safe and powerful adjunct to sonography in prenatal diagnosis. It can provide additional information that aids clinical management, prognostication, and counselling.

Joint effusion of the knee: potentialities and limitations of ultrasonography.

This study aimed at comparing the diagnostic accuracy of ultrasonography (US) and magnetic resonance imaging (MRI) for the detection of joint effusion of the knee. For this retrospective study, approbation by the institutional review board was not required, and written informed consent from the patients was waived. One hundred and fifty-eight patients (83 men and 75 women; median age 41.2years; age range 13-81years) who underwent US and MRI of the knee were included in the study. The sensitivity and specificity of US with respect to MRI in the evaluation of the effusion of the knee and in each recess were compared. In evaluating joint effusion of the knee, compared with MRI, US correctly identified 78 of 96 patients with joint effusion, showing a sensitivity of 81.3% and a specificity of 100%, with a positive predictive value (PPV) of 100% and a negative predictive value (NPV) of 77.5% (p value=0.001). Various results were obtained comparing ultrasound with MRI, regarding the various recesses. US showed high specificity and sensitivity in diagnosing knee joint effusion and could be used in patients who cannot undergo MRI.

Utility of ultrasonography as an auxiliary method in the diagnosis of lesions in oral soft tissues

A review was made of the literature about the indications, advantages, and limitations of ultrasonography as a complementary examination in the area of odontology during the diagnosis of soft tissue changes in the maxillofacial region. A survey of the PubMed database comprising articles from 2000 to 2013 was performed with the following keywords: intraoral lesions, ultrasonography, diagnosis by imaging, oral soft tissue lesions, and oral pathology. Although ultrasonography is rarely requested by oral surgeons, the results demonstrated its use as a complementary examination that aided in the establishment of differential and/or conclusive diagnoses of innumerable diseases. It can demonstrate the presence of mucous, submucous, cutaneous, or subcutaneous nodules, and their respective diameters and precise localizations. It determines whether lesions are solid or contain liquid, differentiates edemas from abscesses, and identifies cysts, salivary gland pathologies, and vascular lesions, besides contributing to the staging of cervical metastases. Like other available imaging examinations, ultrasonography has specific indications and limitations. However, compared with other methods, it demonstrates widely favorable results for its use. It is suggested that this resource should be promoted in the odontology field as another alternative for obtaining a clinical diagnosis for oromaxillofacial changes. Ultrasonography is an innocuous and non-invasive examination, which is readily available and of low cost, and has eminent potential for assisting in the diagnosis of orofacial soft tissue diseases. However, to date, it has been infrequently used by oral surgeons, who are often not aware of its effective indications and advantages in relation to classical methods of diagnosis.

Section 1. Image evaluation of fatty liver in living donor liver transplantation.

Preoperative evaluation of donors for living-donor liver transplantation aims to select a suitable donor with optimal graft quality and to ensure donor safety. Hepatic steatosis, a common finding in living liver donors, not only influences the outcome of liver transplantation for the recipient but also affects the recovery of the living donor after partial hepatectomy. Histopathologic analysis is the reference standard to detect and quantify fat in the liver, but it is invasive, and results are vulnerable to sampling error. Imaging can be repeated regularly and allows assessment of the entire liver, thus avoiding sampling error. Selection of appropriate imaging methods demands understanding of their advantages and limitations and the suitable clinical setting. This article describes potential clinical applications for liver fat quantification of imaging methods for fat detection and quantification, with an emphasis on the advantages and limitations of ultrasonography, computed tomography, and magnetic resonance imaging for quantifying liver fat.

Inadvertent ureteric trauma with an indwelling urethral catheter: limitations of ultrasonography in urological diagnosis

We present a 85-year-old man with a suspected diagnosis of urosepsis and a background of a permanent indwelling catheter, which was consequently shown to have been misplaced in his left ureter. This rare phenomenon is associated with a significant diagnostic dilemma resulting in unrecognised damage unless the clinician has a high index of suspicion. Our […]

Imaging indications in polymyalgia rheumatica

With the recent improvement in technology, various imaging modalities are increasingly being used in the diagnosis and monitoring of musculoskeletal diseases. Although polymyalgia rheumatica (PMR) is traditionally considered a ‘clinical diagnosis’ the utility of imaging for diagnosis, assessment of disease severity and treatment response in PMR is increasingly recognized. Imaging not only adds to the diagnosis by detecting PMR-specific features, but also helps to make alternative diagnoses. Recently published classification criteria emphasize the importance of ultrasonography, an easily available imaging modality in the diagnosis of PMR. Herein we discuss the role and limitations of ultrasonography, MRI and fludeoxyglucose-PET scanning in the management of PMR, particularly in the diagnosis, and distinguishing it from its numerous mimics.

Adenomyosis at Hysterectomy: Prevalence, Patient Characteristics, Clinical Profile and Histopatholgical Findings

Underlying adenomyosis is often the cause of treatment failure for patients undergoing medical therapy for abnormal uterine bleeding and or chronic pelvic pain. Given the limitation of ultrasonography in diagnosing adenomyosis and MRI being unaffordable to most of the patients belonging to developing countries like us, it often remains undiagnosed before a hysterectomy. To find out the clinical profile associated with adenomyosis and to determine the prevalence of adenomyosis in hysterectomy specimens; frequency distribution, as well as to correlate clinical examination with histopathological examination. A total of 60 women who had undergone hysterectomy with histopathologically proven adenomyosis between April 2009 and March 2010 were included . Data were collected on indication for the intervention, age, symptoms, clinical findings, hemoglobin, menopausal status, gross and histopathological findings. A total of 256 women were scheduled for hysterectomy. Adenomyosis was diagnosed in 60 of 256 cases (23.4%). Menorrhagia (91.2%), dysmenorrhoea (84.2%), lower abdominal pain (84.2%) beginning later in reproductive life (mean age- 45yrs) is the classic presentation. Adenomyosis was present in 10 of 61 patients (16.3%) with fibroids; 27 of 60 (45%) with abnormal uterine bleeding; 11 of 55 (20%) with prolapse; four of 35 (11.4%) with ovarian mass; five of 25 (20%) with chronic pelvic pain; three of four (75%) with endometriosis. Women undergoing hysterectomy with diagnosis of adenomyosis have a distinct symptomatology. The choice of therapy in adenomyosis is hysterectomy for those women who have completed family and had failed medical therapy .

Predictive Value of Current Imaging Modalities for the Detection of Urolithiasis During Pregnancy: a Multicenter, Longitudinal Study

We determined the optimal imaging study by which to diagnose and treat pregnant patients with suspected urolithiasis. A retrospective, multicenter study was performed to determine the comparative accuracy of imaging modalities used before the surgical management of suspected urolithiasis in pregnant patients. Patients with a clinical suspicion of urolithiasis were evaluated with directed imaging including renal ultrasound alone, renal ultrasound and low dose computerized tomography, or renal ultrasound and magnetic resonance urography. When indicated, patients underwent therapeutic ureteroscopy. The rate of negative ureteroscopy was determined and the positive predictive values of the imaging modalities were calculated. A total of 51 pregnant patients underwent ureteroscopy. The mean age of the cohort was 27 years. Mean gestational age was 24.4 weeks. Of the women 24 (47%) underwent renal ultrasound and low dose computerized tomography, 22 (43%) underwent ultrasound alone, and 5 (10%) underwent renal ultrasound and magnetic resonance urography. Negative ureteroscopy occurred in 7 of the 51 patients (14%). The rate of negative ureteroscopy among patients who underwent renal ultrasound alone, renal ultrasound and low dose computerized tomography, and renal ultrasound and magnetic resonance urography was 23%, 4.2% and 20%, respectively. The positive predictive value of computerized tomography, magnetic resonance and ultrasound was 95.8%, 80% and 77%, respectively. The rate of negative ureteroscopy was 14% among pregnant women undergoing intervention in our series. Of the group treated surgically after imaging with ultrasound alone, 23% had no ureteral stone, resulting in the lowest positive predictive value of the modalities used. Alternative imaging techniques, particularly low dose computerized tomography, offer improved diagnostic information that can optimize management and obviate unnecessary intervention.